Class _.3CL^2 

Book_^Cf r l _ 



COPYRIGHT DEPOSIT 



DIFFERENTIAL DIAGNOSIS 

AND 

TREATMENT OF DISEASE 



A TEXT-BOOK FOR PRACTITIONERS 
AND ADVANCED STUDENTS 



BY 

AUGUSTUS CAILLE, M. D. 

Fellow of the New York Academy of Medicine ; Member and ex-President of the 
American Paediatric Society ; Professor of Diseases of Children, New York 
Post-Graduate Medical School and Hospital ; Visiting Physician to 
the New York Post-Graduate and German Hospitals ; Con- 
sulting Physician to Isabella Home and Hospital, etc. 



WITH TWO HUNDRED AND TWENTY-EIGHT 
ILLUSTRATIONS IN THE TEXT 




LIBRARY of CONGRESS 
Two Copies Received 

NOV 18 1905 

Copyright Entry 
CLASS a, XXc. No, 
COPY B. 



Copyright, 1905, by 
D. APPLETON AND COMPANY 



PRINTED AT THE APPLETON PRESS 
NEW YORK, U. S. A. 



TO 

THE MEMORY OF 
ERNESTINE AND EMMA CAILLE 
THIS WORK IS DEDICATED 



PREFACE 



To bring the broad domain of practical medicine fairly within the grasp 
of the family physician, and to assist the advanced student in acquiring a clin- 
ical foundation has been my aim. 

The general practitioner, representing the unity and connection of the 
various branches of medical practice, must grasp the practical details of his 
art in order to be useful at the bedside; and a book to be of value to the family 
physician should convey clinical experience without the exhaustive and often 
purely theoretical details to be found and sought for in monographs. Such 
a work I have endeavored to write. 

It has been my desire to reestablish the relations of internal medicine, 
surgery, and the several specialties; for this reason I have presented special- 
ists methods from the view-point of the general clinician. Disease is neither 
medical nor surgical nor does it hover on the border lines, but the treatment 
of disease has become more surgical and the arbitary division into medical 
and surgical disease is no longer tenable. This unitarian principle should 
not be ignored in the presentation of disease, and many methods of diag- 
nosis and treatment originally worked out by the specialist have become, or 
should become, common property. 

Drugs no longer' dominate our therapeutics; therefore the prominence 
given to hygienic, prophylactic, dietetic, hydrotherapeutic, and physical 
methods of treatment. At the same time well-tried and valuable formula? are 
distributed throughout the book. 

In prescription writing the apothecaries' weight and not the metric system 
has been used. However, simple rules for converting one into the other are 
given. 

The special chapters on the Technique of Diagnosis and Laboratory 
Aids, on Paediatrics, and the various specialties, on diseases of the Osseous, 
Muscular, and Articular System, on Nutrition and Diet, on the Management 
of Dropsy and Effusion, on Massage, Vibration, Dry Hot Air Treatment, 
Poisons and Anaesthesia, it is to be hoped will not. be an unwelcome addition 
to a book on practice. Each chapter is prefaced by a synopsis of its contents 
and by brief introductory remarks on the clinical pathology of its subjects. 

In writing this book a lucid brevity in general diction has been the aim 
of the author. 

The bulk of this volume is from the author's pen. 

The chapter on Orthopaedics was contributed by Dr. C. Jaeger, Chief of 
the Orthopaedic Department of Vanderbilt Clinic, New York. 



vi 



PREFACE 



My brother, Wm. Caille, D.D.S., is the author of the Essay on the Care 
of the Teeth. Dr. R. L. Loughran has contributed Instructions for Keep- 
ing Case Records and Accounts. 

Dr. R. H. Halsey and Dr. H. B. Sheffield, both instructors in Medicine 
in the New York Post-Graduate Medical School and Hospital, have given val- 
uable aid in preparing the chapter on Infectious Fevers and Dermatological 
Memoranda. 

In revising some of the special chapters, the author has received helpful 
suggestions from Dr. T. M. Brooks, Professor of Histology and Pathology ; 
Dr. G. M. Edebohls, Professor of Gynaecology; Dr. F. Torek, Professor of 
Surgery; Dr. G. M. Schlapp, Neurologist, Cornell University; and Dr. C. 
Mund, New York Ophthalmic and Aural Institute. 

Dr. I. H. Berry has aided faithfully in arranging the manuscript, and 
my assistants in various institutions have helped to collect histories and 
original illustrations. The very excellent index is the work of Miss M. S. E. 
Cars well. 

The author tenders appreciative thanks to all who have aided in this 
undertaking. To the publishers, thanks are due for their unvarying courtesy 
and hearty cooperation during the preparation of the work. 

Augustus CailiA 

753 Madison Avenue, New York. 



CONTENTS 



Introduction: The Requisites of the General Practitioner, his Relation to the Commu- 



nity and to Specialism 1 • 

CHAPTER I 

THE TECHNIQUE OF DIAGNOSIS AND LABORATORY AIDS TO CLINICAL DIAGNOSIS 

The technique of diagnosis 9 

Introductory remarks 9 

The causes of disease . .• . . . 10 

General examination 10 

Regional examination 15 

Special examinations 16 

CHAPTER I — Concluded 

LABORATORY AIDS TO CLINICAL DIAGNOSIS 

Examination of the urine 17 

Chemical tests 19 

Microscopical examination of urine 24 

Examination of feces 27 

Characteristics 27 

Microscopical examination of feces 28 

Worms 30 

Clinical examination of the stomach contents ■ . . . .31 

Microscopical examination 32 

Chemical analysis 32 

Examination of sputum 35 

Transudates, puncture fluids, cyst contents 37 

Exudates 38 

Stains ' 40 

Breast milk 40 

Cultures 40 

Blood • 42 

Significance of hyperleucocytosis 44 

Preparation of blood slides 44 

Diseases requiring blood examination 45 

Tissue specimens 50 

Analysis of drinking water 51 

Calculi 51 

Cytodiagnosis, cytolysis, etc. 52 

Cryoscopy 54 

Phloridzin test 55 

Directions for preparing specimens 55 



viii 



CONTENTS 



CHAPTER II 



GENERAL THERAPEUTIC MANAGEMENT 

PAGE 

Introductory remarks 57 

Feeding in sickness 57 

Rectal alimentation — Nutrient enemata 59 

Gavage 60 

Flushing the stomach and the bowels; lavage 60 

Enteroclysis — Low and high enemata and colon inflation 63 

Antipyretic measures 64 

Drug antipyretics . . .65 

Hydrotherapy; balneotherapeutics 65 

Cold air 69 

Stimulation 69 

Drug stimulation 71 

General symptomatic management 73 

Dyspeptic symptoms and thirst 73 

Laxatives in acute illness • ... 74 

Diaphoretics and diuretics 74 

Expectorants and cough mixtures 75 

Inhalations 77 

Dyspncea 77 

Pain in acute and chronic illr.ess 78 

Nervousness and insomnia in the absence of pain . 78 

Venesection and depletion 79 

The nasopharyngeal toilet 80 

Tonics in the convalescent stage 82 

Mental therapeutics and work for the sick 83 

Invalid bed 85 

CHAPTER III 

PEDIATRICS 

Care of the new-born . . . . . 87 

Points to be observed by nurses 89 

When children begin to walk 92 

Diseases of the new-born 92 

Deformities; malformations 102 

Infant feeding 107 

Breast feeding; maternal nursing 107 

How to nurse .111 

Facts about milk 113 

Standard of cleanliness 113 

Rationale of milk sterilization 114 

Pancreatized milk (peptonized milk) 115 

Diluents of cow's milk 116 

Milk laboratories and prescription writing for milk food 118 

Babcock milk tester 118 

Cow's milk for infant feeding 119 



Diet for children after weaning or during the second year of bottle feeding and 

after three years 

Disorders of the digestive tract 



CONTENTS ix 

PAGE 

Ailments of the mouth in children 126 

Mumps; parotitis 128 

Indigestion and diarrhoeal disorders 129 

Habitual constipation and difficulties of defalcation in infants 129 

Colic and vomiting 129 

Acute indigestion 130 

Acute catarrhal gastritis in infants 131 

Difficult feeding cases in bottle fed infants (prolonged indigestion) . . . .132 

Chronic indigestion in older children 133 

Acute forms of diarrhoea 134 

Dyspeptic diarrhoea; simple diarrhoea 134 

Severe acute forms of diarrhoea 134 

Enterocolitis, or follicular enteritis 139 

Membranous enteritis, or dysentery 139 

Chronic diarrhoea 140 

Malnutrition and intestinal toxaemia (marasmus, rhachitis, scurvy) . . . 142 

Rickets, rhachitis 143 

Scurvy in children 145 

Worms in children 148 

Tuberculous peritonitis in children 149 

Diseases of the respiratory tract in children .150 

Introductory remarks . . 150 

Catching cold 151 

The clinical features of acute bronchitis in children 152 

Bronchopneumonia in children (catarrhal pneumonia, capillary bronchitis) . . 153 

Acute lobar pneumonia in children (fibrinous, or croupous, pneumonia) . . . 157 

Circulatory failure and stimulation in pneumonia 160 

Pleuropneumonia — Pleurisy with serous effusion and pyothorax in children . . 160 

The significance of fever following operations for pyothorax 167 

Whooping cough; pertussis 168 

Thymus gland; enlargement and abscess 170 

Enlarged bronchial lymph nodes 171 

Diphtheria .171 

Paralysis and ataxia following diphtheria 179 

Croup 179 

Intubation and tracheotomy 183 

Disinfection of the sick room 190 

Tonsillitis, peritonsillitis; quinsy 191 

Hypertrophic tonsils in children 193 

Adenoid growths and their removal 195 

Retropharyngeal lymphadenitis and abscess 197 

Eruptive and other fevers 198 

Measles; morbilli 198 

Rubella; rotheln; German measles 200 

Varicella (chickenpox) 201 

Scarlet fever 201 

Glandular fever 206 

Malaria in children 207 

Typhoid fever in children 207 

^Vulvovaginitis 208 

Masturbation in infants (thigh friction) 209 

Familiar forms of nervous derangements peculiar to early life 209 

Tics; habit spasms; paroxysmal running in children 209 



X 



CONTENTS 



PAGE 

Head nodding and nystagmus in rhachitic children 210 

Night and day terrors (pavor nocturnus et diurnus) . . . . . . .211 

Tetany in infancy (pseudo tetanus) . . .211 

Laryngismus stridulus (laryngospasm) 212 

Enuresis; bed wetting; incontinence 213 

Convulsions in children 214 

Chorea (St. Vitus's dance) 215 

The paralyses of infancy and childhood 215 

Meningitis in children 220 

Hydrocephalus 225 

Disorders of speech: Stammering, stuttering, and lisping 226 

Hysteria in children 226 

Mental defects from arrested developments 228 

Idiocy; imbecility; cretinism; mutism 228 

CHAPTER IV 

THE DIGESTIVE SYSTEM 

Nutrition and diet 

Introductory remarks 229 

Remarks on digestibility of food 230 

The absorption of food 230 

The components of food ' 231 

Practical dietetics: Liquid, soft, restricted, and special diet 235 

Stimulants and beverages 236 

Predigested food .238 

Concentrated foods 238 

Systems of diet 239 

Vegetarianism ■ 240 

Exercise and digestion 240 

Tobacco, food, and digestion 241 

CHAPTER V 

the digestive system — Continued 

Diseases of the mouth 242 

The care of the teeth 250 

The care and treatment of the temporary set of teeth 251 

Shedding of the temporary and eruption of the permanent set .... 252 

Cleaning the teeth 254 

Remarks on pulpitis-periostitis, alveolar abscess, and alveolar pyorrhoea . . 255 

Remarks on the emergency treatment of toothache 255 

Brief remarks on the regulation of the teeth 256 

Family type of dental deformity 256 

CHAPTER VI 

the digestive system — Continued 

Diseases of the oesophagus 257 

Introductory remarks . 257 

Anomalies of the oesophagus 257 

Acute inflammations of the oesophagus 258 



CONTENTS xi 

PAGE 

Chronic inflammations of the oesophagus — Ulcer and cancer 258 

Stricture, paralysis, rupture, diverticulum, etc 259 

Paralysis of the oesophagus 26 1 

Rupture of the oesophagus 261 

Foreign bodies in the oesophagus 261 

CHAPTER VII 

the digestive system — Continued 

Clinical pathology of the stomach and intestine and diagnostic technique . . . 262 

Remarks on the clinical pathology of the stomach 262 

Motor phenomena and neurosis 262 

Sensory phenomena of the stomach 263 

Secretory phenomena of the stomach 263 

Hydrochloric acid, HC1 264 

Digestive ferments - . . . . . . . 265 

Diagnostic technique 266 

Remarks on the clinical pathology of the intestine 268 

Motor phenomena 269 

Sensory phenomena 270 

Diagnostic technique 270 

CHAPTER VIII 

the digestive system — Continued 

Gastrointestinal ailments in adults . 273 

Acute dyspepsia; acute indigestion; gastricismus 273 

Acute gastritis, simple, phlegmonous, toxic, infectious, parasitic .... 273 

Chronic dyspepsia 274 

Clinical varieties of chronic dyspepsia 274 

Dyspepsia with dilatation or atony of the stomach 276 

Chronic nervous dyspepsia 277 

Secretory neuroses of the stomach 278 

Dyspepsia with hyperchlorhydria (hyperacidity) 278 

Erosions and ulcer of the stomach 279 

Cancer of the stomach 280 

Syphilis of the stomach 281 

Benign tumors of the stomach 281 

Haemorrhage from the stomach 281 

Gastrointestinal neuralgia (cardialgia, gastralgia, enteralgia, colic, "stomach 

cramps") 282 

Indications for operations on the stomach 283 

Constipation; obstipation; faecal impaction 283 

Tympanites and dilatation of the colon 287 

Dilatation of the bowel, congenital and acquired 288 

Acute catarrhal enteritis 288 

Acute gastroenteritis in adults; cholera morbus 289 

Chronic enteritis 290 

Dysentery in adults ■ 290 

Intestinal ulcer 291 

Tuberculosis of the intestine r: ..... . 292 



xii 



CONTENTS 



PAGE 

Appendicitis ... 292 

Diagnostic palpation of the appendix vermiformis . ... 292 

Benign and malignant neoplasms of the intestine 295 

Intestinal obstruction, acute and chronic 296 

Haemorrhage from the intestines 297 

Remarks on strangulated hernia and taxis 297 

Intestinal parasites 298 

Enteroptosis; splanchnoptosis; Glenard's disease 300 

Intestinal putrefaction and toxaemia; autoinfection from the intestines; intestinal 

antisepsis 301 

CHAPTER IX 

the digestive system — Continued 

Proctological memoranda (rectal ailments) 304 

Preliminary remarks 304 

Catarrh of the rectum; proctitis 304 

Impaction of faeces 305 

Fistula in ano 306 

Haemorrhoids (piles) 306 

Rectal polypi 308 

Pruritus ani 308 

Prolapse of the rectum 309 

Simple fissure and ulcer of the rectum 309 

Ulceration and stricture of the rectum 310 

Neuralgia of the rectum 311 

Coccygodynia 311 

The upper rectum and sigmoid flexure 312 

CHAPTER X 
the digestive system — Concluded 

Diseases of the liver 313 

General remarks 313 

Jaundice as a symptom . 314 

Catarrhal jaundice in older children and adults 315 

Hyperemia or congestion of the liver 316 

Acute yellow atrophy of the liver; malignant jaundice 316 

Cirrhosis of the liver 317 

Abscess of the liver and suppurative pylephlebitis 318 

New growths of the liver 319 

Hydatid cysts of the liver (echinococcus) 320 

Chronic degenerative processes in the liver 321 

Disease of the gall bladder and bile ducts 321 

Acute catarrh of the bile ducts (not caused by gallstones) 321 

Gallstones 321 

Cancer of the biliary apparatus ............ 324 

Diseases of the pancreas 324 

General remarks 325 

Acute hemorrhagic pancreatitis . 325 

Acute suppurative pancreatitis 325 

Tumors of the pancreas 326 



CONTENTS Xlii 

PAGE 

Cysts of the pancreas 326 

Pancreatic calculus 328 

Diseases of the peritonaeum, omentum, and mesenteric glands 329 

Acute peritonitis 329 

Subphrenic peritonitis (abscess) 331 

Chronic peritonitis ■ 331 

Cancer of the peritonaeum and omentum 332 

The omentum and mesentery 332 

Mesenteric and retroperitoneal glands 332 

CHAPTER XI 

THE CIRCULATORY SYSTEM 

Remarks on the clinical pathology of the circulation 333 

Congenital heart defects 335 

Clinical aspect of hypertrophy and dilatation ......... 336 

Acute circulatory failure (heart strain, shock, collapse, rupture) .... 338 

Endocarditis, acute and chronic 339 

Pericarditis; adherent pericardium; chronic adherent pericardium .... 341 

CHAPTER XII 

THE circulatory system — Continued 

Muscular and valvular insufficiency of the heart and heart neuroses . . . 344 

Weak heart; congenitally small heart; flabby heart muscle 344 

The fat-laden heart (cor adiposum) 345 

Chronic degeneration of the heart muscle not due to valvular defects . . . 346 

The senile heart and arteriosclerosis 346 

Valvular heart disease 347 

Signs and symptoms of valvular lesions 348 

Diagnosis and prognosis of congenital heart disease 351 

Principles of treatment '. ... 351 

Visceral neuralgias in heart disease simulating other disease 355 

Neuroses of the heart 356 

Simple palpitation 356 

Arrhythmia of the heart 357 

Tachycardia (paroxysmal rapid heart) 358 

Bradycardia 358 

Spurious angina pectoris 358 

Angina pectoris • 359 

Diseases of the arteries and veins 359 

Arteriosclerosis (atheroma) 360 

Phlebitis (inflammation of veins) 361 

Varicose veins . .361 

Aneurysm . 362 

Aneurysm of the aortic arch 362 

Aneurysm of the abdominal aorta 363 

Lymphatic system . . . . . . . 363 

General remarks 363 

Lymphangeitis and lymphadenitis — Lymph stasis . . . . . . . 364 



xiv 



CONTENTS 



CHAPTER XIII 
the circulatory system — Continued 

PAGE 

Conditions of the blood ■ . 368 

Terminology and definition 368 

Leucocytosis 371 

Anaemia 372 

Simple anaemia from haemorrhage 372 

Progressive pernicious anaemia . ... . . 374 

Anaemia secondary to other diseases 375 

Leucaemia (leucocythaemia) 377 

Lymphatic leucaemia 378 

Diagnosis of leucaemia, treatment, etc 379 

Pseudoleucsemia 380 

Splenic anaemia 381 

Purpura and the hemorrhagic diathesis 382 

Haemophilia; hemorrhagic diathesis; bleeders 384 

Remarks on hemorrhage: external, internal, visible, invisible .... 385 

Septicaemia and pyaemia (blood poisoning) 385 

CHAPTER XIV 

the circulatory system — Concluded 

Clinical forms and therapeutic management of dropsy and effusion .... 387 

Anasarca; general oedema 388 

General management 388 

(Edema of the lower extremities 389 

Ascites 391 

Management of ascites 391 

Hydrothorax; pleuritic effusion 393 

Aspiration from the patient's standpoint 397 

Acute and chronic hydrocephalus; hydrencephaloid, or wet brain; cranial and spinal 

puncture 397 

Acute and subacute pulmonary oedema 399 

Collateral, or inflammatory, oedema 402 

Unilateral oedema from thrombosis and pressure 403 

Encysted dropsy; retention cysts; serous cysts 404 

Hydronephrosis . 404 

Dropsy of the gall bladder 404 

Hydrosalpinx 405 

Hydrocele 405 

Serous cysts 405 

Hydatid cysts 406 

Dropsy of the amnion (hydramnios) 4 06 

(Edema bullosum of the urinary bladder 406 

Dropsy of joints (hydrarthros); dropsy of bursae 4 °6 

Dropsy of tendons, tendon cysts, simple ganglion 4 06 

Resume' of diagnostic punctures ... 407 



CONTENTS 



XV 



CHAPTER XV 



THE RESPIRATORY SYSTEM 

PAGE 

The upper respiratory tract 409 

Remarks on clinical pathology of the respiratory tract 409 

Rhinological and laryngological memoranda 411 

Examination of the upper respiratory tract 411 

Autoscopy and tracheoscopy 412 

Catching cold 413 

Nasal obstruction 415 

Hypertrophic rhinitis 416 

Chronic pharyngitis 416 

Chronic laryngitis 417 

Atrophic forms of rhinitis, pharyngitis, and laryngitis 418 

Erosions and ulcers in the upper respiratory tract 418 

New growths, benign and malignant, of the upper respiratory tract .... 420 

Foreign bodies in the upper respiratory tract 422 

Haemorrhage from the upper respiratory tract (epistaxis) 423 

Nasal deformities 423 

Disease of the accessory sinuses of the nose 424 

The tonsil in adults 424 

Phlegmonous amygdalitis with circumtonsillar abscess 424 

Hypertrophy of the tonsils 425 

The use of the tonsillar knife and tonsillar clipper ... ... 426 

Mycosis of the pharynx and tonsils 426 

Respiratory obstruction 426 

(Edema of the larynx or glottis 426 

Neuroses and paralyses of the upper respiratory tract 427 

Vasomotor rhinitis; hay fever; pollen fever 427 

Neuroses of the pharynx 428 

Neuroses of the larynx 428 

Formulae for nose and throat treatment 429 

CHAPTER XVI 

the respiratory system — Concluded 

Deep respiratory tract 431 

Clinical features of pulmonary congestion, oedema, etc 431 

Pulmonary congestion (active, passive, hypostatic) 431 

Pulmonary infarction or apoplexy 432 

Abscess of the lung 432 

Gangrene of the lung 433 

Haemorrhage from the lung (haemoptysis) 433 

Acute forms of bronchitis in adults 434 

Acute bronchopneumonia (catarrhal pneumonia; capillary bronchitis) . . . 435 

Acute tuberculous bronchopneumonia (hasty, or galloping, consumption) . . 437 

Acute lobar pneumonia; fibrinous pneumonitis in adults 438 

Chronic forms of bronchitis and bronchopneumonia 442 

Simple chronic bronchitis 442 

Chronic fibrinous bronchitis 442 

Emphysema of the lung 444 

Pneumoconiosis 445 

1 



xvi CONTENTS 

PAGE 

Bronchiectasis .... 446 

Cirrhosis of the lung (chronic interstitial pneumonia) 446 

Chronic pulmonary tuberculosis; tuberculous bronchopneumonia; consumption; 

phthisis 446 

Bronchial asthma 457 

Acute and chronic pleurisy 460 

Dry, fibrinous, or plastic pleurisy 461 

Effusive pleurisy ; wet pleurisy 461 

Chronic pleurisy . 464 

Hydrothorax; hemothorax; pyothorax; pneumothorax 464 

Intrathoracic tumors and cysts (benign tumors; dermoid and hydatid cysts; malig- 
nant tumors) 46^- 

Affections of the mediastinum 468 

CHAPTER XVII 

THE GENITOURINARY SYSTEM 

Diseases of the genitorurinary organs 460 

Remarks on the clinical pathology of the genitourinary tract 469 

Systemic poisoning from kidney insufficiency 471 

Remarks on albuminuria 471 

Hematuria 472 

Hemoglobinuria 473 

Pyuria; pus in the urine 474 

Polyuria, oliguria, and anuria 474 

Calculi .475 

Remarks on urination, catheterism, and vesical emergencies 475 

Remarks on renal insufficiency and newer aids to diagnosis 476 

Cystoscopy, ureteral catheterism, and cryoscopy 477 

Diseases of the kidney 477 

General remarks on diagnosis 477 

Congestion of the kidneys; hyperemia of the kidneys; rupture of kidney . . 477 

Remarks on acute and chronic nephritis CBright's disease) 478 

Acute nephritis 479 

Chronic nephritis (chronic Bright's disease) 479 

Chronic parenchymatous nephritis 479 

Chronic interstitial nephritis; cirrhosis of the kidney; contracted kidney . . 480 

The surgical treatment of acute and chronic nephritis 481 

Uremia in nephritis 481 

Pyelitis and pyelonephritis; pyelonephrosis; surgical kidney 482 

Perinephritic abscess 483 

Movable kidney; floating kidney 484 

Summary of diagnostic points in kidney lesions . . . ... . . 485 

The ureters 485 

Ailments of the urinary bladder 486 

Acute chronic and ulcerative cystitis and pericystitis 487 

Stone in the genitourinary tract 48£ 

Syphilis of the genitourinary tract 49( 

. Tuberculosis of the genitourinary tract 491 

Benign and malignant new growths .... 49 j 

Parasites of the genitourinary tract 49' 

Localized and minor ailments of the male genital organs . . . . . .49: 



CONTENTS XVii 

PAGE 

Penis 492 

Urethra 493 

Prostate 494 

Testicles and spermatic cord 495 

CHAPTER XVIII 

the genitourinary system — Continued 

Venereal disease in the male and female, and derangements of the sexual function in 

the male 497 

Syphilis in adults and children 493 

Hereditary syphilis; congenital syphilis; syphilis hereditaria tarda .... 500 

Chancroid; soft chancre; ulcus molle 501 

Gonorrhoea in the male and female, adult and child; remarks on its complications 

and sequelae 502 

Venereal disease in the female 505 

Functional derangements in the male 505 

Sexual erethism; masturbation; pollution 505 

CHAPTER XIX 

the genitourinary system — Concluded 

Gynecological memoranda 508 

Menstrual disorders 516 

Menstrual colic; dysmenorrhcea; intermenstrual pain; lumbar neuralgia . . 517 

The menopause and premature menopause 518 

Incontinence of urine in the adult female 519 

Sterility in the female 519 

Vaginimus 520 

Vulvovaginal discharges .521 

Inflammation and abscess of the vulvovaginal glands 522 

Prolapse and malposition of the uterus and ovaries 523 

Prolapse of the uterus, ovaries, and bladder 523 

Laceration of the perinaeum and cervix 524 

Ectopic gestation . 525 

Pelvic haematocele 525 

Pelvic inflammation and suppuration in the female 526 

Benign and new growths of the female pelvis 527 

Polypi 527 

Cystic tumors of the ovaries and broad ligaments 527 

Dermoid cysts of the ovary and ligaments 528 

Ovarian fibromata 528 

Uterine fibroid tumors 528 

Malignant new growths; sarcomata and carcinomata 529 

Cancer of the cervix uteri ' 529 

Cancer of the body of the uterus 530 

Malignant tumors of the ovary 530 

Abortion; miscarriage 530 

Puerperal sepsis 531 



xvni 



CONTENTS 



CHAPTER XX 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 

PAGE 

Diseases of bone 533 

Remarks on the pathology of inflammation in bone 533 

Acute bone inflammation 535 

Osteoperiostitis 535 

Acute infectious osteomyelitis 535 

Acute epiphysitis 536 

Pyaemic abscess of bone 536 

Chronic inflammation of bone 536 

Tuberculosis of bone 536 

Syphilis of bone . 538 

Actinomycosis of bone 539 

Benign tumors of bone 539 

Malignant tumors of bone 540 

Osteomalacia (mollifies ossium) 542 

CHAPTER XXI 

osseous, muscular, and articular system — Continued 

Diseases of joints and bursas 544 

General remarks 544 

Clinical varieties of joint lesions 545 

Sprains 545 

Synovitis 546 

Arthritis 546 

Joint affections in bleeders; scurvy and gout 547 

Acute articular rheumatism; rheumatic fever 547 

Manifestations of rheumatism in children 550 

Arthritis deformans 551 

Chronic rheumatic arthritis; chronic rheumatism 556 

Syphilitic arthritis 556 

Tuberculosis of the joints 557 

Loose bodies in joints 558 

Displacement of the semilunar cartilages 559 

Neoplasms of joints 559 

Neuroses of joints 559 

Neuropathic arthritis 559 

Bursitis 560 

CHAPTER XXII 

osseous, muscular, and articular system — Continued 

Diseases of muscles, tendons, and fascia? 561 

The muscles ■ 5.61 

The muscular dystrophies 565 

The tendons 566 

The fasciae ' 568 



CONTENTS xix 

CHAPTER XXIII 

osseous, muscular, and articular system — Continued 

PAGE 

Orthopaedic memoranda 569 

Wolfe's law 569 

Pott's disease . 569 

Torticollis 575 

Lateral curvature of the spine 576 

Rigid spine; spondylitis deformans (spondylose rhizomelique) 579 

Hip disease 580 

Congenital dislocation of the hip 583 

Coxa vara 586 

Knee disease 587 

Achillodynia 589 

Anterior metatarsalgia 589 

Anterior poliomyelitis and paralytic club foot 591 

Flat foot 592 

Flat foot of children 595 

CHAPTER XXIV 

osseous, muscular, and articular system — Concluded 

Massage, Swedish movements, vibratory stimulation, and hot air treatment . . 596 

Remarks on massage and Swedish movements 596 

Massage treatment of the digestive and pelvic organs 597 

Massage as an aid to the circulation of blood and lymph 597 

Treatment of stiff joints by massage and movements 598 

Treatment of sprains by early massage 598 

Mechanical vibration; vibratory massage; vibratory stimulation .... 600 

Dry hot air treatment 600 

CHAPTER XXV 
infectious and contagious fevers 

Introductory remarks 602 

Remarks on prophylaxis and disinfection 603 

Infectious and contagious fevers 609 

Malarial or intermittent fevers 609 

Enteric fevers (typhoid and para-typhoid fevers) ........ 616 

Treatment of complications and sequelae 624 

Influenza 625 

Yellow fever 627 

Typhus fever 628 

Dengue 630 

Relapsing fever 631 

Cholera asiatica 632 

Variola 634 

Vaccinia, or cowpox; vaccination 640 

Bubonic plague; pest; black death 641 



XX 



CONTENTS 



CHAPTER XXVI 

DISEASES DUE TO FAULTY METABOLISM, TO FAULTY INTERNAL SECRETIONS, AND TO 
DERANGEMENTS OF THE DUCTLESS GLANDS 



PAGE 

Gout 643 

Glycosuria and diabetes meJlitus 651 

Obesity 658 

Scurvy, scorbutus, in adults 661 

Derangements of the ductless glands 664 

The thyreoid gland 664 

Myxcedema 664 

Hypothyreoidism 666 

Cretinism (congenital myxcedema; myxcedema of childhood) 666 

Basedow's disease (Parry's disease; Grave's disease; exophthalmic goitre) . . 667 

The suprarenal gland 670 

Addison's disease (morbus Addisonii; bronzed disease) 670 

Diseases of the pituitary body 672 

Acromegaly 672 

The spleen 673 

General remarks 673 

Splenic anaemia 674 

CHAPTER XXVII 

THE NERVOUS SYSTEM; NEUROLOGICAL MEMORANDA 

Remarks on the clinical pathology of the nervous system 675 

Motor phenomena 676 

Paralysis and paresis 676 

Sensory, secretory, and special sense phenomena 679 

Reflexes 679 

Trophic disturbances 681 

Remarks on aphasia 681 

Psychical conditions 681 

Insomnia (sleeplessness) 681 

Familiar points in cerebral localization 681 

Remarks on the application of electricity 681 

Action of the electric current upon living tissues 682 

Electricity in practice 682 

Examination scheme in nervous derangements 683 

The nerve clinic 685 

Neuralgias; painful tics; headache; migraine 685 

Forms of neuralgia 685 

General principles of treatment of neuralgias 687 

Headache 688 

Migraine; hemicrania (sick headache) 689 



Disturbances with predominating undue motion of central, peripheral, or unknown 



origin; (tics) . . 691. 

Occupation neuroses • • • .691 

Tetany; pseudotetanus 693 

Paralysis agitans (shaking palsy; Parkinson's disease) 693 

Obstinate hiccough 694 



CONTENTS xxi 

PAGE 

Disturbances with loss of power of motion predominating (palsies, acute and chronic) 695 

Cerebral apoplexy (haemorrhage, embolism, and thrombosis) 695 

Bulbar paralysis (glossolabiolaryngeal paralysis) 697 

Ophthalmoplegia 697 

Spinal apoplexy . . . . " 698 

Anterior poliomyelitis 698 

Spinal progressive muscular atrophy; wasting palsy (Aran-Duchenne type) . . 698 

Progressive hereditary muscular atrophy, perineal (Charcot-Marie type) . . 699 

Amytrophic lateral sclerosis 700 

Lateral sclerosis 700 

Locomotor ataxia (tabes dorsalis; posterior spinal sclerosis) 701 

Hereditary ataxia (Friedreich's ataxia) . 704 

Ataxia paraplegia (combined sclerosis) 704 

Myelitis 704 

Acute ascending paralysis (Landry's paralysis) 707 

Syringomyelia . . . 707 

Cerebrospinal sclerosis (multiple or disseminated sclerosis) 707 

Diver's paralysis (caisson disease) 708 

Cranial nerve palsies 708 

Neuritis 711 

Multiple neuritis ■ 712 

Disturbances with loss of consciousness predominating 714 

Vertigo . . 714 

Delirium 715 

Coma 718 

Eclampsia; convulsions 718 

Puerperal eclampsia 718 

Epilepsy 721 

Sleeping sickness; negro lethargy; trypanosomiasis 725 

Derangements with psychical alterations predominating 725 

Neurasthenia 726 

The traumatic neuroses; traumatic hysteria 730 

Insomnia 731 

Hypnotism, or suggestion; trance 732 

Classification of mental disturbances 733 

Vasomotor and trophic disturbances 734 

Raynaud's disease 734 

. Erythromelalgia 735 

Meningitis in adults 737 

General diagnostic and therapeutic remarks 737 

Acute and chronic leptomeningitis in adults 739 

Acute cerebral leptomeningitis 739 

Acute spinal leptomeningitis 741 

Chronic meningitis (chronic leptomeningitis) 741 ■ 

Chronic leptomeningitis spinalis 742 

Cerebrospinal meningitis in adults 743 

Tuberculous meningitis in adults 747 

Acute external pachymeningitis 747 

Chronic internal pachymeningitis 748 

Spinal pachymeningitis ■ 748 

Pachymeningitis externa spinalis 748 

Pachymeningitis interna hemorrhagica spinalis * 748 

Pachymeningitis interna hypertrophica spinalis 748 



xxii 



CONTENTS 



PAGE 

Syphilis of the nervous system 749 

Syphilitic endarteritis 749 

Syphilitic toxaemia 749 

Syphilitic exudations into the meninges 749 

Other syphilitic conditions 750 

Miscellaneous lesions in the brain and spinal cord in which localization and surgical aid 

is possible 751 

Injuries to the brain 751 

Contusion and laceration .751 

Meningeal haemorrhage 752 

Haemorrhage between the dura mater and the skull 752 

Haemorrhage between the dura mater and the pia mater 752 

Concussion of the brain 753 

Compression of the brain 754 

Tumors of the brain 757 

Thrombosis of the venous sinuses 760 

Abscess of the brain (suppurative encephalitis) 761 

Parasites of the brain 762 

Injuries of the spinal cord 763 

Haemorrhage into the spinal membranes 763 

Remarks on the sympathetic nervous system 765 

Anatomical anomalies 765 

Abnormities of the brain 765 

Malformations of the spinal cord 766 

Spina bifida (rhachischisis posterior) 766 

Other malformations 767 

Stigmata of degeneration (Peterson) 767 

Remarks on idiocy and amaurotic family idiocy 767 

Amaurotic family idiocy 768 



CHAPTER XXVIII 



DERM ATO LOGICAL MEMORANDA 



Introductory remarks 769 

Diseases of the glandular apparatus 770 

Sweat glands 771 

Sebaceous glands 771 

Seborrhcea (acne sebacea; tinea furfuracea; dandruff) 772 

Anomalies of pigmentation 772 

Chloasma; vitiligo; lentigo; albinismus 772 

Inflammations 772 

Dermatitis 773 

Ecthyma 776 

Eczema (tetter; salt rheum; scall) ' 776 

Erythema 777 

Herpes 777 

Impetigo 778 

Ichthyosis (fish skin disease) 778 

Lichen 779 

Miliaria (sudamina; prickly heat) strophulus 779 

Pemphigus (water blisters) 779 

Pityriasis 780 



CONTENTS xxiii 

PAGE 

Prurigo 780 

Psoriasis (lepra alphos) 780 

Sclerema (neonatorum) 781 

Scleroderma (hide-bound disease) 781 

Urticaria (hives; nettle rash) 781 

Xeroderma (xerosis) 782 

Parasitic skin diseases 782 

Animal .782 

Vegetable 782 

Neoplasms and new growths 789 

Benign . 789 

Malignant neoplasms 793 

Dermatoneuroses 795 

Sensory dermatoneuroses 795 

Motor dermatoneuroses 796 

Trophic dermatoneuroses 796 

Chronic trophoneurotic erythema 796 

Vascular dermatoneuroses 796 

Mai perforans (perforating ulcer of the foot) . . . 796 

Diseases of the appendages 797 

The hair 797 

Atrophy of the hair; alopecia (baldness) 797 

Hypertrophy of the hair 797 

The nails 797 

Formulary 798 

CHAPTER XXIX 

OTIC MEMORANDA 

General remarks 806 

Minor local ailments in or about the ear 807 

Otitis media, acute and chronic 808 

Mastoid disease 809 

Sense of hearing 809 

Diagnostic value of fluid discharges from the ear in head injuries 811 

Formulary 811 

CHAPTER XXX 

OPHTHALMIC MEMORANDA 

General remarks 812 

Sense of sight 812 

The pupils 814 

The ophthalmoscope 815 

Injuries of the eye and foreign bodies 815 

Diseases of the eyelids .816 

Diseases of the lacrymal apparatus 817 

Conjunctivitis and trachoma 817 

Keratitis 818 

Diseases of the sclera, ciliary body, and chorioid 819 

Iritis 819 

Glaucoma 819 



xxiv 



CONTENTS 



Disease of the retina 820 

Detachment of the retina 820" 

Diseases of the optic nerve 822 

Cataract and opacities ■ 821 

Squint, strabismus 821 

Eyesight and eye strain 821 

Eye formulary 822 



CHAPTER XXXI 



ANAESTHESIA, INTOXICATIONS, MISCELLANEOUS AILMENTS, KEEPING CASE RECORDS AND 

ACCOUNTS 

Anaesthesia 823 

Remarks on local and general anaesthesia 823 

Intoxicants 825 

Poisons and antidotes 825 

Insect and snake bites 828 

Drug habits 830 

Alcoholism . ■ 831 

Miscellaneous ailments 831 

Seasickness (mal de mer) 831 

Mountain sickness 832 

Hydrophobia (rabies; lyssa) 832 

Septic wounds and traumatic tetanus 833 

The keeping of records of cases under treatment and their accounts in private practice 833 



LIST OF ILLUSTRATIONS 



FIGURE PAGE 

1. Einhorn Saccharometer 21 

2. Ureometer 23 

3. Scolex and Segments of Taenia Saginata 29 

4. Tania Solium 29 

5. Tsenia Echinococcus, magnified twenty diameters 30 

6. Contents of an Echinococcus Cyst showing Scolices, Hooklets and Cholesterin 

Crystals 30 

7. Ascaris Lumbricoides (roundworms) 30 

8. Oxyuris (pin worms) 30 

9. Haemoglobinometer 42 

10. Thoma-Zeiss Pipettes 43 

11. Counting Slide (plan) 43 

12. Blood Counting Slide (elevation) 45 

13. Blood Counting Diaphragm. Actual Size 45 

14. Counting Blood Cells 46 

15. Making a Blood Smear on a Slide .50 

16. Gavage (feeding by means of the Stomach Tube) 60 

17. Soft Rubber Stomach Tube 61 

18. Stomach Washing in Adults 61 

19. Stomach Washing in Infants by Means of a Fountain Syringe at an Elevation 

of Four Feet 62 

20. T Cannula for Irrigation 62 

21. Bowel Irrigation in Infants and Children 63 

22. Kemp's Rectal Irrigator (double current catheter) 64 

23. Hot Pack 66 

24. Enteroclysis 69 

25. Hypodermoclysis 70 

26. Apparatus for Venous Infusion 73 

27. Atomizer for Albolene 77 

28. Technique of Venesection 79 

29. Dry Cupping 81 

30. Nasopharyngeal Toilet 81 

31. Blunt Nasal Irrigation Syringe 81 

32. Infection and Sloughing of the Skin from Unclean Hypodermatic Injections . 84 

33. Bed Grapple for the Comfort of Patients 84 . 

34. 35. Feely Invalid Bed 85 

36. How to Hold the Baby; Faulty Way, Correct Way 90 

37. Incubator for Premature Children 91 

38. Encephalocele. Vault of Cranium Absent. Age One Year . . . . .98 

39. Encephalocele at Three Years 99 

40. Achondroplasia 100 

41. Enlarged Thymus . . . . . .101 

42. Spina Bifida . . . 102 



XXVi LIST OF ILLUSTRATIONS 

FIGURE PAGE 

43. Thoraco Abdomino Pagus 103 

44. Thoraco Abdomino Pagus (skiagram) 104 

45. Bronchocele 105 

46. Marked Curve of Little Finger of Mongolian Idiot 106 

47. Arnold Sterilizer and Pasteurizer 114 

48. Lactometer . : 118 

49. Cream Testing Outfit 118 

50. Chapin Dipper 121 

51. Seibert's Aluminum Milk Filter, with Cotton Disk 121 

52. Rhacitic Flat Foot in Child of Nine Months 142 

53. Comfortable Position for Children with Rhacitic Weak Back .... 143 

54. Carrying-Frame for Feeble Rhachitic Children 145 

55. Rhachitic Deformity 145 

56. Rhachitis. Genu Varum Before Operation 146 

57. Rhachitis. Genu Varum After Operation ' . . . 146 

58. Rhachitis. Genu Valgum Before Operation 146 

59. Rhachitis. Genu Valgum After Operation 146 

60. Infantile Scurvy and Marasmus 147 

61. Tuberculous Peritonitis with Ascites 148 

62. Tuberculous Peritonitis of Two Years' Standing 149 

63. Tuberculous Peritonitis and Hernia 150 

64. Tuberculous Peritonitis with Cystic Accumulation of Fluid (operation) . . 151 

65. Temperature Curve in a case of Septic Bronchopneumonia in Child, Ending in 

Recovery 154 

66. Fever Curve in Tuberculosis of Lung and Unresolved Pneumonia Compared in 

Cases of Empyema 167 

67. Household Reflector 172 

68. Intubation Tube in Situ (skiagram) ... 180 

69. Intubation Tube in Situ (skiagram) 182 

70. O'Dwyer's Instrument Set 183 

71. O'Dwyer's Intubation Instruments 184 

72-75. Technique of Intubation 185 

76. Intubation of the Larynx 186 

77. Intubation Statistics of Budapest Stephanie Children's Hospital .... 187 

78. Larynx of a Child Two and a Half Years Old showing Ulceration . . . 188 

79. Built Up Head for Granulations 189 

80. Author's Automatic Tracheal Retractor 189 

81. Cleansing Tracheotomy Wound with Tube in Situ 190 

82. McKenzie's Tonsillotome . . ■ 193 

83. Tiemann-Fahnenstock Tonsillotome 194 

84. Tonsil Knife 194 

85. Beckmann's Curette for Adenoids 195 

86. Post Nasal Fenestrated Forceps for Adenoids 195 

87. Adenoids Before Operation 195 

88. Adenoids After Operation 195 

89. Adenoids Before Operation 196 

90. Adenoids After Operation 196 

91. Temperature Curve in Measles 199 

92. Pseudohypertrophic Muscular Paralysis 217 

93. Pseudohypertrophic Muscular Paralysis 218 

94. Cerebrospinal Meningitis 221 

95. Meningitis 222 

96. Spinal Puncture. Forward Bicycle Position 223 



LIST OF ILLUSTRATIONS xxvii 

FIGURE PAGE 

97. Ice Water Coil in Meningitis .... ... 224 

98. Hydrocephalus ... 225 

99. One Year Old Child 227 

100. Same Child. Pronounced Cretin at Two Years 227 

101. Same Child. Four Weeks After Treatment with Thyreoid 227 

102. Same Child. Ten Weeks After Treatment with Thyreoid 227 

103. Showing Sixth Year Molar Teeth 251 

104. 105. Showing Set of Teeth at Six Years 252, 253 

106. Showing Set of Teeth at Eleven Years 254 

107. Introducing (Esophageal Bougie 260 

108. Illumination of the Stomach by Means of Fluorescein and the Electric Light . 267 

109. Enteroclysis 284 

110. Tuberculous Ulcer of the Ileum ' . . . .291 

111. Represents a Properly Applied Truss for the Retension of Double Inguinal 

Hernia . 298 

112. Skein of Worsted Truss 298 

113. Abdominal Support, Plaster and Webbing 301 

114. Cancer of the Liver 319 

115. Dulness in Hypertrophy of the Left Ventricle 337 

116. Showing the Dulness due to Dilatation and Hypertrophy of Both Ventricles . 338 

117. Rupture of the Heart . . 339 

118. The Triangular Area of Dulness due to a Large Pericardial Effusion, Shown by 

the Outer Solid Line 342 

119. Aortic Aneurysm 362 

120. Unique Case of Chronic Lymph Stasis 364 

121. Splenomedullary Leucaemia 379 

122. Longitudinal Scarification for (Edema . . 390 

123. Tapping the Abdomen under Local Anaesthesia 392 

124. Permanent Drainage for Ascites 393 

125. Exploratory Puncture of the Chest under Ethyl Chloride Local Anaesthesia . 394 

126. Aspirator 395 

127. Heat Vacuum Aspirator 396 

128. Examination of the Anterior Nose by Means of a Nasal Speculum and Reflected 

Light 412 

129. Laryngoscopy and Posterior Rhinoscopy 413 

130. Bivalve Nasal Speculum 414 

131. Spray Tubes 415 

132. Albolene Atomizer 416 

133. Snaring Posterior Nasal Hypertrophies 417 

134. Fibroma of the Vocal Cord 420 

135. Jarvis' Snare, Straight or Curved 421 

136. Congenital Papilloma of Larynx 421 

137. Epithelioma of the Larynx 421 

138. Sarcoma of the Epiglottis 422 

139. Peritonsillar Abscess 425 

140. Effect of One Dose of Quinia in a Case of Malarial Bronchopneumonia . . . 435 

141. Diphtheritic Bronchial and Tracheal Cast 436 

142. Fibronous Cast of the Bronchi 443 

143. Skiagram of Normal Thorax 448 

144. Skiagram. Right Lung Cavernous, Left Lung Consolidated .... 449 

145. Sanitary Pocket Cuspidor 451 

146. Paper Cuspidor 451 

147. Window Tent for Open Air Treatment at Home 452 



XXVlii LIST OF ILLUSTRATIONS 

FIGURE PAGE 

148. Cut of Window Tent showing Ventilation ... ... 453 

149. Out Door Rest Cure 454 

150. Out Door Rest Cure . 455 

151. The Tucker Tent 456 

152. Lung Gymnastics 463 

153. Sources of Pyuria 474 

154. Sacculated Prolapse of the Right Ureter 485 

155. For Bladder Irrigation 488 

156. Urethral Hand Syringe 504 

157. Urethroscope * 504 

158. Stocking and Strap Leg Holder in Dorsal Posture 509 

159. Bimanual Palpation of Female Pelvic Organs (No. 1) 510 

160. Bimanual Palpation of Female Pelvic Organs (No. 2) 511 

161. Supporting Belt .522 

162. Sub-Urethral Abscess . . ■ 522 

163. Prolapse of the Ovary 523 

164. Abdominal Support of Plaster and Webbing 524 

165. Pelvic Haematoma 525 

166. Pelvic Abscess 526 

167. Tuberculosis of Os Calcis 537 

168. Tuberculous Focus in Tibia, Healed. Skiagram 538 

169. Tuberculous Knee Disease 538 

170. Tuberculous Disease of Elbow 539 

171. Osteomalacia Deformity 542 

172. Strapping the Knee 545 

173. Arthritis Deformans of Spine 552 

174. Hip Disease Showing Flexion Deformity 557 

175. Charcot Knee Joint (Tabes Dorsalis) 560 

176. Trichina Spiralis Encysted in Muscle 564 

177. Contracture of Palmar Fascia 568 

178. Bradford Carrying Frame for Pott's Disease 570 

179. Bradford Frame— Child Able to Walk ......... 570 

180. Pott's Disease Plaster Jacket and Headspring 571 

181. High Cervical Pott's Disease, showing Characteristic Posture of Child . . 572 

182. Spinal Tuberculous Abscess 573 

183. Cervical Pott's Disease, showing Characteristic Broadening of the Neck . . 574 

184. Pott's Disease, showing Kyphos and Abscess 575 

185. Applying Plaster of Paris Jacket 576 

186. Torticollis showing Facial Asymmetry ' . 577 

187. Scoliosis 578 

188. Exercise for Scoliosis 579 

189. Hip Splint 580 

190. Bed Extension in Hip Disease 581 

191. Lorenz Spica 583 

192. Double Spica after Reduction of Double Congenital Dislocation of Hip . . 584 

193. Lorenz Hip Redresseur 585 

194. Coxa Vara 586 

195. Bow Legs and Congenital Deformity of Upper Extremity 588 

196. Knock Knee 589) 

197. Club Foot ... 590 

198. Talipes Equinus from Infantile Paralysis 591 

199. Talipes Calcaneus - . 592 

200. Krukenberg's Pendulum Apparatus for Treatment of Flat Foot .... 593 



LIST OF ILLUSTRATIONS xxix 

FIGURE PACE 

201. Flat Foot . 594 

202. Dry Hot Air Treatment 598 

203. Application of the Chattanooga Vibrator 599 

204. Dry Hot Air Treatment for Arm or Leg 600 

205. Formaldehyde Sterilizer 607 

206. Tertian Malaria 613 

207. Typhoid Fever in Berlin Before and After Sand Filtration of Drinking Water . 617 

208. Pulse, Respiration and Fever Curve in Uncomplicated Typhoid Fever . . 620 

209. The Value of Vaccination 635 

210. Spastic Paraplegia 677 

211. Muscular Dystrophy 678 

212. Muscular Dystrophy 679 

213. Symmetrical Gangrene 735 

214. Hemiatrophia Facialis Progressiva . . 736 

215. Dressing for Ulcer of the Leg 773 

216. Gauze Mask and Splints to Prevent Scratching in Eczema . . . . 776 

217. Contagious Impetigo . . 778 

218. Pediculus Pubis 782 

219. Male and Female of Sarcoptes Scabiei 783 

220. Papulo-Pustular Syphilide sent to Municipal Hospital as a Case of Smallpox . 787 

221. Eustachian Catheters 806 

222. Examination of the Ear 807 

223. Double Current Irrigator for the Ear 810 

224. Opthalmoscopic Examination 813 

225. Emergency Poisoning Case 830 

226. Case Record 834 

227. Case Record 835 

228. Day-Book and Ledger 836 



INTRODUCTION 



To be able to recognize the clinical form of disease and to aid nature in 
its reparative endeavors is the aim of the physician. The time was, and it is 
within the memory of many of us, when the family practitioner was the trusted 
family counselor in all matters concerning health and sickness. Before the 
advent of antisepsis and specialism and the acceptance of the germ theory 
in medicine, every mature and successful practitioner was the authority for 
his clientele. Disease was looked upon as a visitation of Providence, the 
belief in the virtues of drugs and medicines was absolute, and surgery was 
brutal and simple. 

At the opening of the twentieth century no profession stands in a more 
advanced position than that of medicine. General and local anaesthesia, 
asepsis and antisepsis, chemical and bacteriological research, with subsequent 
therapeutics on entirely new lines (serum and organotherapy) have opened 
up vast diagnostic and therapeutic possibilities. 

Anaesthesia, antiseptic wound treatment, and antitoxines have reduced 
the sum total of pain and misery. The introduction of cocaine has been 
followed by a rapid development of the nose and throat specialty and has 
made the work of the time-honored ophthalmologist easier. Bacteriology 
and chemical research have given to all departments in the practice of medicine 
a marvelous diagnostic precision, complexity of terms, and an avalanche of 
literature which have completely swamped the all-round medical man, and 
make it difficult for the special worker in medicine to keep abreast of the 
times and events. 

Owing to the great strides which practical and theoretical medicine have 
made in the past twenty-five years, the position of the general practitioner 
to-day is a peculiar one. He has found it impossible to keep abreast with the 
rapid progress in medicine; any young specialist feels himself his superior 
in his particular line, and, in our large cities, among the wealthy class, the 
general practitioner finds himself little more than " master of the ceremonies " 
— the diagnosis and treatment are furnished by the various consultants and 
the patient is handled by the trained nurse. 

These matters have been discussed at various times and from divers stand- 
points, but no definite and precise advice has been formulated for the guidance 
of the student, or prospective student, or young practitioner, who in his en- 
thusiasm for the study of medicine fails to take into consideration the great 
difficulties which beset him in the practice of his chosen profession. 

It may not be out of place (before analyzing the future prospects of the 
family practitioner) to answer the question " To what extent shall we en- 
courage young men and women to take up the practice of medicine as a liveli- 
2 1 



2 



INTRODUCTION 



hood? " To judge from the large number of medical men who are yearly let 
loose upon the public, it would appear that medicine is looked upon as a very 
promising field for reward, in fame and riches. Such an assumption is, how- 
ever, not warranted by existing conditions. The law of supply and demand 
i- inexorable, and we may have an overstocked profession just as we may 
have an overstocked market in flour or cheese. 

Owing to the fact that many have entered the medical profession from 
impulse or fancy, the production of medical practitioners has been far ahead 
of the demand, and although an increase in population and the dropping out 
of the old members of our profession will make room for newcomers, there 
will certainly not be room for all who are clamoring for admission to its ranks. 
To my mind no one should attempt to enter upon such a career without a good 
physical constitution, a sound mind, a tactful disposition, and a thorough 
appreciation of the situation which confronts him, a full understanding of 
i he ditliculi h - to i .<• overcome, and the hard work and drudgery to be endured 
by the general practitioner, be he successful or not. Competition is a stern 
master; it elevates and degrades, and the position of the medical man who 
in the battle of life has lowered his standard of honesty and loses his self- 
respect by reason of practices unworthy of a gentleman and a true physician 
is a deplorable one, be the money reward small or great. 

Is (here a place in society for the family practitioner, and if so, under what 
precise conditions will he be in demand? 

1 firmly believe that the family practitioner is not doomed to become 
extinct and that in due time the people will again elevate him to the position 
ol t rusted family counselor, and this opinion I hold for two reasons principally. 

In the firsl place, many intelligent people who are fortunate enough to 
have the services of a thoroughly good family practitioner have refused to 
give him up and have upheld the dignity of his position on every occasion 
where t he counsel and services of a specialist were in demand ; and in the second 
place the public has already experienced the many and serious drawbacks of 
an indiscriminate consultation with immature specialists whose advice, if 
followed, has in many instances been bought more dearly than by dollars 
and cents. 

Much of the specialist work of to-day is worthy of the highest praise; 
on the other hand, a large percentage of operative work is ill advised, super- 
fluous, and harmful, and as soon as the more intelligent people of the com- 
munity realize thai such Is the case they will again turn for advice to the 
intelligent family practitioner; they will admit him again to the inner family 
council and trust to him to shield them from the meddlesome treatment of 
our times and deliver them into conservative and safe hands. And if the 
future family practitioner is to regain lost ground, again aspire to reach that 
Plane m the practice of general medicine which is properly his, and again 
enjoy the full confidence of his clientele, it must be through his own individual 
' torts by educating himself to become a diagnostician. In view of the com- 
!'!• '■- '■harac,,,-. w | m . h are features of some of the special examinations, this 
mav herculean task, but I am convinced that all medical men who 

are ntted by nature and proper education for their work, will in reasonable 
,,m ". compete* diagnosticians and will be capable of formulating 

precise indications for treatment, provided ample opportunity for laboratory 



INTRODUCTION 



8 



and bedside instruction be offered and sought, and provided that no time be 
wasted experimenting with thousands of old and new and useless drugs in 
the endeavor to adapt a complex, cumbersome, and largely superfluous materia 
medica to the various symptoms of acute and chronic illness. 

The general practitioner must be: 1. Master of physical diagnosis. 2. He 
must have some laboratory training, particularly if he practises far away 
from laboratory facilities. 3. He must be able to make a local or regional 
examination, employing such of the methods of specialists which have become 
general property. 4. He must have a good knowledge of hygiene and dietet- 
ics. 5. He must be able to practise minor surgery and be able to perform 
emergency operations. 6. Whenever feasible, obstetrical cases should not 
be handled by the general practitioner. 

A thorough training in physical diagnosis is the basis of a successful 
medical career. Once properly learned, it is never forgotten, and as long as 
we are in active practice, auscultation and percussion are and should be our 
daily routine work. 

The various orifices of the body are accessible to the finger (touch), or, 
by means of simple instruments or specula, they are accessible to sight, 
and it is certainly lack of energy and self-confidence if the general prac- 
titioner fails to make use of ordinary local examination methods which 
may have been first introduced by the specialist, but have long ago become 
public property. 

The intelligent layman will understand that the family doctor may not 
be prepared for a thorough ophthalmoscopic or cystoscopic examination, 
but why he should require other men to look into the mouth, nose, throat, and 
other regions, or to siphon out the stomach contents, and send fluids and 
blood to the laboratory for examination, is something he will not understand, 
and if he finds from experience that for local examinations a double fee will 
be entailed — that of the family doctor and that of the specialist — he will 
soon come to the conclusion that he may as well go to headquarters at once 
without consulting the family doctor at all. Things are very different when 
a patient is sent to a specialist for a corroboration of diagnosis or opinion. 
Two heads are sometimes better than one, and in obscure or serious cases a 
medical man will not suffer in the estimation of his patient if he requests the 
counsel or services of a professional colleague. 

Under all circumstances the general practitioner should direct his energies 
to making a diagnosis himself and formulating precise indications for treatment. 
His patients will understand that he can not be a Jack of all trades and perform 
everything, but they will expect him to make a diagnosis and suggest proper 
treatment. 

The attendance upon obstetrical cases has always been one of the duties 
of the general practitioner, and medical men have felt that from the first 
successful confinement case in a family dates the firm position which they 
may have eventually held as the family attendant. 

Now, there are two reasons why the general practitioner should not as a 
rule attend obstetrical cases. The minor reason is that such cases usually in- 
volve night work, and a physician who works from 8 a. m. to 10 p. m. should go 
to bed and sleep unless called out by some serious emergency case. Life is 
short and we are entitled to some creature comforts. The important point is, 



4 



INTRODUCTION 



thai a general practitioner is at all times in contact with contagious or com- 
municaMe disease and may, in fact does, infect parturient women. The more 
intelligenl women in city practice will readily accept the services of an ob- 
stetrician other than the family doctor, if it is made clear to them that they 
escape the dangers of childbed fever and its sequelae by such management. 
Amonu; tin' |>oor people a well trained midwife who knows how to disinfect 
her hands is a safer attendant upon a woman in labor than the general prac- 
titioner who comes from a case of scarlet fever or erysipelas and is for some 
reason or other always in a great hurry and prone to help things along by 
the aid of his forceps. 

Tins field properly belongs to that class of practitioners whose chief work 
is obstetrics, to which almost all their time must be allotted to do full justice 
to their cases. 

How far such an arrangement might be possible in country practice remains 
to be seen. 

This hurry and bustle in the life of the general practitioner is all wrong 
and for the safety of our patients is bad. 

The general practitioner must fight against and not encourage the hys- 
terical activity of our times. He should give time and thought to his cases, 
and his fee should be in accordance with the time spent and with the circum- 
stances of the patient. 

As things stand to-day the general practitioner is not sufficiently paid for 
his services and is compelled to see more patients than is proper or safe. An 
overworked brain is responsible for such sins of omission as are occasionally 
laid at the door of medical practitioners. Sins of commission are not frequent. 
The remedy lies more with the people than with the profession. A " fussy " 
doctor who turns a household upside down on every occasion of illness, severe 
or trivial, is a very popular person among a certain and large class of people 
who delight in boring their friends and acquaintances with the harrowing 
details of their latest sickness and miraculous escape from sure death. Physi- 
cians are needlessly called out at night; they are not sufficiently paid, and a 
proper understanding of the situation by our patients would do more to set 
the pace of the doctor than anything else. 

To counterbalance the deficit which must result from the loss of fees for 
obstetrical work, the general practitioner will have more time to devote to 
hinisell and his family, and more time and ambition to practise minor surgery. 
Minor surgery, in my opinion, belongs to the general practitioner. The 
practice of minor surgery is easy and it is more impressive to the laity than 
the writing of a prescription for a lot of useless and superfluous drugs. A 
id practitioner without surgical training and tendencies is handicapped 
from the very start. As he is brought into early contact with cases requiring 
surgical aid, his t imely recognition of the case and use of the knife will be of 
the greatest importance and value in cases which, if seen at a late stage by 
the special surgeon, frequently necessitate extensive surgical interference. 
Local and general anaesthesia have robbed surgery of much of its brutality. 
The knife in conservative hands aids nature and frequently gives prompt 
relief from pain and dangerous symptoms, and it is for this reason that surgeons 
i:ei la rue foes for small operations and the timid general practitioner gets little 
or nothing. Disease does not run its course as purely medical or purely 



INTRODUCTION 



5 



surgical. Such a division does not exist in nature. Rheumatism, typhoid 
fever, tuberculosis, pneumonia, diabetes, and a host of other so called medical 
diseases often present complicating features requiring surgical knowledge and 
interference, which the general practitioner will detect or remedy in good time 
if he has the necessary and proper education, and vice versa, purely surgical 
cases frequently develop non-surgical complications. Thus the Simon-pure 
prescription-writer has no future in the modern practice of medicine, and the 
medical man or woman who does not care to handle the knife should drift 
into a mild, bloodless specialty. Just how far the general practitioner may go 
in the practice of surgical handicraft will depend upon the taste and fancy 
of the individual. Every man will know his limitation and will do well to call 
in a special surgeon in cases requiring strict asepsis and in cases of a graver 
nature. 

For small towns or in country practice I should advocate that neighboring 
general practitioners combine for the purpose of assisting one another in cases 
of minor surgery, emergency operations and the like, and trained nurses 
should be encouraged to locate in small towns for the purpose of aiding the 
medical men by making the usual preparations for operation and by nursing 
such cases after operation. I would suggest that a nurse who has been taught 
massage, diet kitchen work, and obstetrical nursing, in addition to ordinary 
nursing, should be encouraged to locate as above, and I feel that such a one 
would often get into a greater sphere of usefulness than by remaining in the 
large cities with their competitive overcrowding. I regard it as essential that 
the rural community should be educated as to the necessity and desirability 
of such services. 

Another point of great interest to the general practitioner is the labora- 
tory work (clinical microscopy and chemical research), without which no one 
can practise medicine with comfort to himself and his patients, because it is 
necessary for correct diagnosis. The microscope shows us a series of specific 
microorganisms, also changes in tissues and blood; and pathological changes 
in digestive and eliminative organs may sometimes be inferred from a clinical 
examination of various secretions. 

But it must not for a moment be inferred that the general practitioner 
must do all this work himself, for this would be an impossibility. Fine labora- 
tory work is a speciality in itself, and all that is required in this line of the prac- 
tical physician of to-day are the very gross urinary, blood, and sputum tests, 
and stomach contents tests which can be made in short order. Everything 
else should go to the laboratory to be examined by experts, and patients should 
be told that a fee for laboratory work will be asked. In large cities, laboratories 
have been established by private enterprise or in connection with the medical 
schools and hospitals, and for the general practitioner it is no more necessary 
to have a private laboratory than it is to have his own drug shop or his own 
livery-stable. As a matter of expediency and convenience all ordinary simple 
examinations can be made as heretofore in the office. 

We can not with good grace dismiss the general practitioner and his re- 
quirements without speaking in plain language in condemnation of the drug- 
ging habit of which he is still guilty to a remarkable degree. Cabalistic 
prescriptions are still as thick as flies in summer, and the majority of our 
patients pay willingly and handsomely for our wisdom transmitted to them 



6 



INTRODUCTION 



in t lie shape of nauseating mixtures from the time-honored shelves of the 
apothecary shop. 

I know from personal observation that our cousins across the water do 
not presenile or swallow one quarter as much medicine as we do in our country. 
With but few exceptions the entire vegetable and mineral kingdoms have 
given us little of specific value, but still up to the present day the bulk of 
our books on materia medica is made up of descriptions of many valueless 
drugs and preparations. 

[a it nol to be deplored that valuable time should be wasted in our student 
days by cramming into our heads a lot of therapeutic ballast, and is it not 
true that such teaching is to a large degree responsible for the desire on the 
pari of the many practitioners to prescribe frequently and without good cause 
an unnecessary quantity of useless drugs ? 

Every few weeks new drugs and combinations of medicaments are forced 
upon physicians with the claim that they are specifics in the treatment of 
disease, and the physician in his anxiety to alleviate his patients' sufferings, 
because I he simpler and more reliable have failed him, is gulled into trying 
the newly extolled remedy, only to find that it is still less efficacious than the 
old one. 

The common sense practitioner knows by experience that the constant fre- 
quent prescribing of innumerable drugs only ends in detriment to his patients. 
A working knowledge of hygiene and dietetics, climate, hydro- and mechano- 
therapeutics, simple medication and few drugs are the successful agents in 
internal medicine, and the sooner the physician will condense his pharmacopoeia 
and materia medica to a vest pocket edition the sooner will his efforts meet with 
success in the practice of his profession, and the sooner will Christian Science 
delusions disappear from the surface. 

There is -t ill one point which must be discussed and that is: How shall the 
general practitioner keep up with the progress of our art? 

Here again the city colleague has an advantage over the country prac- 
titioner, inasmuch as he lues all the time in a medical atmosphere of Hospital, 
Dispensary, College, Clinic, and progressive and representative medical men. 
If the country practitioner would keep abreast of the time, he must in addition 
to reading a few thoroughly good journals, take a postgraduate course as 
often as his time and circumstances will permit. All honor to the men and 
women who leave their work and travel hundreds and thousands of miles for 
postgraduate instruction. No other profession can boast of more unselfish 
and honorable instincts than are shown by the rank and file of the medical 
profession in a search for the best and most advanced knowledge in the prac- 
tice of the healing art. 

Hospital and dispensary material is not utilized for the purpose of instruct- 
ing as it should be. The best hospitals are teaching hospitals, and the best 
place to obtain postgraduate instruction in medicine is in a teaching hospital 
which offers bedside instruction all the year round. In addition to the position 
of interne- in hospitals there should be a system of externes, or matriculates, 
with a term of service of from three to six months— to act as junior assistants 
or dressers and thus to be brought into intimate contact with the vast material 
"I our large institutions. Our city hospitals should have a country branch 
with a large corps of dressers and assistants for the treatment of subacute 



INTRODUCTION 



7 



and chronic cases and convalescents. It is love's labor lost to keep medical 
and surgical cases longer in the wards of a city hospital than is necessary. 
Convalescents need sunshine, good air, exercise, hydrotherapeutics, and the 
like. Well to do convalescents go to the mountains and seashore if con- 
valescent from acute illness. It would cost less to treat poor convalescents 
in the country, and give better results. The tendency to erect costly and 
elaborate hospital buildings in the city is in many instances a concession to 
our love of outward show and splendor. 

I would venture to express the opinion that all medical men should start 
as general practitioners. If for any reason whatsoever they find it advisable 
to practice a specialty, they will be more generously informed and better 
equipped in every way by reason of years of general practice and experience. 
I predict that the successful general practitioner of the future will be a diagnos- 
tician, sanitarian, and minor surgeon, and after years of active practice such 
a general practitioner will develop into a valuable and conservative general 
consultant. 

Just as the old temple of iEsculapius, held together by a cement of super- 
stition and ignorance, has fallen, and a new temple is being erected, decorated 
with the magnificent works indicative of the progress of our times, so the old 
general practitioner with his obsolete methods and drugs is bound to go — ■ 
and in his place will arise the modern family practitioner, the diagnostician 
and sanitarian, who will find his way along the trails and paths blazed for him 
by the master minds of the past, right into the hearts and confidence of the 
people. 



CHAPTER I 



THE TECHNIQUE OF DIAGNOSIS AND LABORATORY AIDS 
TO CLINICAL DIAGNOSIS 

THE TECHNIQUE OF DIAGNOSIS 

Synopsis: Introductory Remarks. — The Causes of Disease. — Diagnostic Inquiry, General 
Examination. — The Patient's Statement of his Case. — Anamnesic Data. — Miscella- 
neous Signs. — The Recognition and Grouping of Symptoms. — The Significance of 
Fever and Pain. — The Preliminary Examination of the Urine and Blood. — Regional 
Examination. — Examination with X Rays. — Transillumination. — Tuberculin Test. — 
Exploratory Puncture and Incision. — Examination under Anaesthesia. — Examination 
of a Comatose Patient. 

INTRODUCTORY REMARKS 

Although a certain amount of material success is possible in the practice 
of medicine by symptomatic management without a clear knowledge of clinical 
pathology, the physician who aims to practise the healing art to the best ad- 
vantage of the patient and with some degree of personal comfort and satis- 
faction must be able to make a diagnosis. 

To select the right path when so many intricate symptoms are present is 
assuredly not easy. The novice in woodcraft who endeavors to find his way 
through an unknown territory over hills and valleys and streams is bewildered 
in the same manner, and must be content at first to follow in the footsteps of 
the more experienced guide. 

Modern diagnosis is based upon the recognition of symptoms, regional land- 
marks, and upon laboratory research. As diagnosis has become more scientific 
and exact, the art of medicine has become more practical, owing to the elimi- 
nation of deductive reasoning. In place of the latter, laboratory methods, 
inspection, palpation, percussion, auscultation, direct view with specula, 
lens, and mirror; x rays, exploratory incision, and puncture have furnished 
countless diagnostic possibilities and enabled the practitioner to attain a high 
degree of precision. 

To establish a correct diagnosis may require days. 

Systematic investigation, practice, and experience soon make quite easy a 
task which at first appears difficult, so that he who is fitted by nature to act 
as a medical adviser will in time learn to think and act for himself. It should 
be the aim of every general practitioner to become a good all-around diagnos- 
tician ; and, if he fails in this, let him drift into a specialty. 



9 



10 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



THE CAUSES OF DISEASE 

Deviations from normal functions and structure are inherited or ac- 
quired. Hereditary transmission may be temperamental, functional, or 
structural. This includes that imponderable quality known as hereditary 
predisposition. 

lired ailments are the result of traumatism (injury), parasitic invasion 
(infection), intoxication, underfeeding and overfeeding, exposure to extremes 
of heat and cold, suppression of internal secretion, and nerve irritation and 
nerve fatigue from divers causes leading to and producing: Faulty meta- 
bolism, functional and reflex disturbances, or tissue changes and organic 
disturbances, ending in restitution to health or in death, at which time the 
animal body has completed the cycle of its destiny. 

It is the duty of the physician: To educate the individual regarding 
preventive measures, determine the nature of an ailment, and look for and 
remove the source of irritation in functional or organic disorders, to aid 
nat ure iii warding off and overcoming the dangers of acute illness, and relieve 
the suffering incident to progressive organic disease leading to dissolution. 

Inasmuch as nature establishes a fair degree of tolerance as regards the 
discomforts incident to acute and chronic illness, very active symptomatic 
treatment, particularly in chronic ailments, is unnecessary and often meddle- 
some and harmfvl. It may not be out of place to remark that in estimating 
the health or disease status of the individual, we must ever bear in mind that 
a large percentage of persons of all classes come to the physician with im- 
ary ill*, and that hysterical phenomena and malingering are very 

nmon. To a certain extent this assertion holds good even in children. 



DIAGNOSTIC INQUIRY 

GENERAL EXAMINATION 

When a patient comes to us for advice, we make, in accordance with cir- 
cumstances and the time at our disposal: 1. A preliminary examination. 
2. A complete clinical examination. 

I tccasionally our diagnostic probing is handicapped by the comatose or 
delirious state of the patient, or we are compelled to anaesthetize him in 
order to he able to make a careful regional examination. Finally, it may 
be necessary to open the abdomen or other cavities or puncture a cavity, 
tumor, or orjran in order to make an exact diagnosis and suggest and carry out 
proper treatment. Adults are best examined in bed or on a table with most 
of their clothing removed. Children should be completely undressed and 
examined in a good light on a table covered with a pillow or blanket. 

Although the bulk of medical practice is made up of slight ailments, we 
mu.-t not forgel that general symptoms are not pathognomonic and occur in 
Slight ailments as well as in serious illness. 

A diagnosis is made directly or by exclusion by taking into consideration 
'he personal and family history of the patient, his subjective symptoms and 
complaints, the findings of a regional examination, and the findings of the 
laboratory. 



DIAGNOSTIC INQUIRY 



11 



In determining what a disease is, the physician must not go beyond the 
simple facts. 

The Patient's Statement of His Case. — After a few friendly remarks for 
the purpose of putting the patient at his ease, we ask for a recital of the present 
illness and subjective symptoms and make direct or indirect inquiry as to 
its probable cause, manner of onset, duration, and previous management. 
In the case of young children the information is given by the parent. Older 
and intelligent children sometimes give a fair history if they are not frightened. 

Anamnesic Data (to be brought out by the physician). — Name, age, sex, 
condition, occupation, nationality, residence. 

Family History and Previous Personal History, as to : Syphilis 
(chancre), gonorrhea, tuberculosis, cancer, rheumatism, gout, malaria, in- 
temperance, insanity, injuries, menstruation, pregnancies, miscarriages, con- 
vulsions, diseases of childhood, and other diseases. 

Habits. — Tobacco, alcohol, narcotics, coffee, tea, exercise, environment, 
sexual desire, masturbation. 

Nutrition and Subjective Symptoms. — Quantity and quality of food, 
breast or bottle fed, weight (stationary, gain, loss), condition of tongue, 
appetite, bowels, urinary functions, sleep, fever, pain, cough, vertigo, nausea, 
vomiting, and local symptoms. 

For anamnesic data in nervous and mental diseases, see Neurological 
Memoranda. 

Miscellaneous Signs. — The facial expression may indicate pain, anxiety, 
fear, alarm, vacancy, or stupidity, etc. ; the face of impending death, of ad- 
vanced pulmonary tuberculosis, of mouth breathers, of the "typhoid" status, 
of renal disease, (puffy eyelids, etc.) ; the facies of dyspnea (pneumonia 
and pulmonary oedema), of asthma, of exophthalmic goitre, of peritonitis, 
of hysteria. 

Cachexia. — Anaemia, emaciation, and debility are the characteristics of 
cachexia from grave organic disease. The experienced clinician will recognize 
a cancerous, syphilitic, or malarial cachexia, or the cachexia strumipriva, a 
name given to the cachexia resulting from the extirpation of the thyreoid gland 
and characterized by an ana-mic, myxoedematous skin and neurotic disposition. 

Diathesis. — Clinical experience will enable us to speak of a tuberculous 
(scrofulous strumous), gouty (lithaemic), rheumatic, neuropathic, fatty, haemor- 
rhagic, and lymphatic diathesis. 

The Recognition and Grouping of Symptoms. — Aft er securing the anamnesic 
data in a given case of illness, we look for symptoms. 

The multitude of symptoms deserve a word of explanation. They are 
not, as a rule, pathognomonic of a certain diseased condition, nor do they 
point to specific or distinct systemic disturbances, but are found in trivial as 
well as in serious ailments and are not in themselves the basis for conclusions, 
excepting in connection with regional examination, etc. Nausea, a coated 
tongue, and a general feeling of malaise may be due to constipation, or may 
usher in a tuberculous meningitis or some other infection. A cough is a 
prominent symptom in emphysema or membranous croup or it may be due 
to reflex irritation from a follicular pharyngitis, etc. The underlying cause 
of a supraorbital neuralgia may be syphilis, tuberculosis, or malaria, and so 
ad infinitum. Therefore, the treating of symptoms is an illusion and a snare. 



12 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



For practical purposes we shall group the general symptoms according to 
the systemic or organic disturbance to which they point, viz. : 

L. Pointing to Organs of Digestion: Loss of appetite, foetor, coated 
'ic bad taste in mouth, belching of gas, eructations, dysphagia, nausea, 
vomiting, local pain, "dyspeptic asthma," constipation, diarrhoea, flatu- 
lence, tympanites, jaundice, vertigo, headache, phosphaturia, etc. 

2. Pointing to Organs of Circulation: Pallor, cyanosis, flushing, 
oedema, pulsating swellings, dilated and pulsating veins, coldness of hands 
and I'eei. palpitation, throbbing sensations, arrhythmia of heart's action, 
dy-pncea, local pain, vertigo, circulatory or cardiac "asthma," syncope, 
collapse, etc. 

3. Pointing to Organs of Respiration: Sneezing, coryza, nasal voice, 
loss of smell, hoarseness, aphonia, cough, croupy cough, expectoration, haemor- 
rhage, dyspnoea, noisy respiration, pulmonary or respiratory " asthma," local 
pain, perverse sensations, etc. 

[. Pointing to ( 1 i:\itourinary Ailments and those of the Female 
Pelvic Organs and the Rectum: Retention, suppression, or incontinence 
of urine, vesical tenesmus, painful micturition, haematuria, pyuria, albuminuria, 
impotence, abnormal d ischarge, haemorrhage, pain in penis or scrotum, dyspnoea 
or ast hma of renal origin, etc. Bearing down pain in pelvis, menstrual anom- 
alies, intermensi rual pain, leucorrhcea, etc., constipation, incontinence of faeces, 
fecial tenesmus, hemorrhage, pain in rectum, abnormal discharges, etc. 

5. Pointing to Acute Systemic Infection or Intoxication: General 
aching, headache, chill, fever, thirst, weakness, faintness, insomnia, vomiting, 
herpes labialis, convulsions, coma, etc. 

6. Pointing to Nervous and Mental Ailments: Motor, sensory, tro- 
phic, and reflex disturbances, rectum and bladder and ocular phenomena, 
analgesia, neuralgias, tremor, tics, paralysis, paresis, convulsions, girdle sen- 
sation, abnormal gait, nervous asthma, mind wandering, forgetfulness, in- 
somnia, somnolence, aphasia, polyuria, impotence, globus hystericus, delirium, 
hallucination, coma, etc. 

7. Pointing to Disease of the Blood: Anaemic appearance, purpura, 
haemophilia, etc. 

s Pointing to Organs of Locomotion: Pain, abnormal posture and 
B ait < crepitation on motion, muscular rigidity or paralysis, articular rigidity 
or laxity and swelling, false points of motion, etc. 

11 Pointing to the Skin: Itching, burning, discoloration, eruption, and 
other visible manifestations, etc. 

10. Pointing to the Eye: Disturbed vision, headache, eye fatigue on 
reading, burning sensation in lids, dizziness, photophobia, weeping and dis- 
charges, orbital and circumorbital pain, pink eye, etc. 

11. Pointing to the Ear: Previous sore throat, pain and swelling in 
mastoid region, loss of hearing, pain in ear, noises in head or ear, discharges 
from ear, etc. ' & 

12. Pointing to Severe Constitutional Derangements and Grave 
>R< ianic I >ise vsk : Lo SS f appetite, coated tongue, loss of strength and am- 

bit.on, great loss of body weight, insomnia, appearance of cachexia. 



THE SIGNIFICANCE OF FEVER AND PAIN 



13 



The Significance of Fever and Pain 

In order to make a comprehensive presentation of clinical phenomena 
the significance of symptoms will not be discussed in a separate chapter 
and from a diagnostic standpoint, but will receive attention throughout the 
book in connection with the various ailments. At present we shall consider 
only Fever and Pain as general phenomena which we may encounter in any 
and almost all forms of illness. 

Fever. — The normal bodily temperature is 98° to 99° F. The rectal tem- 
perature is about one degree higher than that of the mouth or axilla. For 
taking temperature the clinical thermometer should be inserted into the 
rectum or vagina or under the tongue with lips closed. The temperature 
record taken in the axilla is not reliable. 

To convert the Centigrade into the Fahrenheit scale we divide the Centi- 
grade temperature by 5, multiply the quotient by 9 and add 32. To convert 
the Reaumur scale into Fahrenheit we divide by 4, multiply by 9 and add 32. 

Fever is characterized by rise of body temperature plus a disturbed 
metabolism. A normal temperature is maintained by means of a complicated 
system of heat regulating apparatus the details of which are more of physio- 
logical than clinical import. An increase of body temperature is usually 
accompanied by a respiratory increase. In fever there is a contraction of 
surface capillaries; the skin cools off and the patient experiences a chilly 
feeling, chills. We also observe chills with fever temperature and a reddened 
skin with dilated capillaries. A nervous chill is unattended by rise of tem- 
perature. An increase of body temperature is usually accompanied by an 
increase of body oxidation, particularly albumin oxidation; and thus we find 
in the febrile state an increase of urea in the urine. 

In the convalescent stage of acute infectious disease, the regulation of the 
body heat is liable to be disturbed by trivial causes. Thus, in typhoid con- 
valescents a rise of temperature is observed when nourishment is taken in 
excess. 

In order to produce fever by infection, bacteria or their products must enter 
the circulation. The same holds good for the protozoa (malaria). We 
have no definite knowledge regarding the purely nervous irritation of the 
heat centres. The predisposition to fever temperature varies with the in- 
dividual and with his age and condition of the individual. This is a well 
known clinical fact. Young and strong individuals have a higher range of 
fever heat than the weak and aged. As a rule, continued high fever is accom- 
panied by loss of appetite and inanition. Here, again, there are exceptions. 
The writer has known children and adults to have temperatures of 104° for 
over a week and still retain an excellent appetite. 

Continued high fever is accompanied by structural change in the liver, 
kidneys, heart, and muscles. Frequently, a loss of body weight is not observed 
during the fever period, but is noticed during convalescence. 

The significance of fever for the organism is still a mooted question. On 
the one side fever is looked upon as a direct danger, and, contrariwise, a high 
temperature is looked upon as favoring a limitation of disease conditions. 
Naturally, our therapeutic efforts will vary according to our personal con- 
ception of such conditions. At the present time we are still in the dark regard- 



14 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



Lng i hese points and we do not exactly know whether a fever from an infection 
i favorable or unfavorable or of neutral importance to the animal economy. 
Thus our antipyretic efforts through hydrotherapy or chemical antipyretics 
may or may nol be of value in a given case, but may be rational as favoring 
increased elimination through the skin, etc. Our knowledge regarding sub- 
normal temperature is meagre. 

The temperature is a very important aid to diagnosis. A fever tempera- 
lure may mean very little, but it always means something, and should stimu- 
late us to look for and, if possible, to find the cause. A single notation of 
temperal ure is not of much value in obscure disease, and it frequently becomes 
necessary to study the temperature curve extending over one, two, or more 
week-. A daily remission to the normal usually excludes typhoid fever and 
speaks for malaria. L'nrcsolccd pneumonia and tuberculous pneumonia show 
a marked difference in the temperature curve. A sudden rise of temperature 
following an operation puts us on our guard for a complication. Mild abdomi- 
nal symptoms ami a low fever curve in children, in the absence of a painful 
appendix and of Widal's typhoid fever reaction, are suggestive of tuberculous 
peritonitis. Tims, in obscure cases, the patient, if not in a hospital or under 
the care of a trained nurse, must be taught to take and note his temperature 

eral t imes a day. According to the writer's observations, adults and chil- 
dren with valvular heart lesions sometimes have a "normal" temperature 
of 100° F. In acute indigestion in children very high temperatures are ob- 
served, and some children show very high temperature from any slight cause. 
The term aseptic fever is sometimes employed by surgeons to designate a 
rise of temperature following an operation which can not be localized as to 
cause and which is unaccompanied by other symptoms of septic infection. 

Clinically, high temperatures have been observed in tetanic muscular con- 
tractions, in infectious diseases, in insolation, and in lesions of the bulbocervical 
cord. In acute illness the temperature may be taken every four hours or at 
the time of a chill. In chronic illness once or twice a day is sufficient. The 
various types of fever— continued, remittent, intermittent, irregular, etc.— 
will lie mentioned in their clinical relations to disease. 

Pain ; Tenderness ; Paraesthesia ; Headache.— Pain may be acute or dull 
or paroxysmal or shifting— gnawing or crampy or tenesmic or pulsating. It 
may increase by motion and disappear on firm pressure. 

Pam, as a symptom in children and adult neurotics, is not always a reliable 
factor on which to base a conclusion. The cause or origin of a given pain is 
to be made out by the associated signs and symptoms. It is generally true 
that if weehcit tenderness in an organ that organ is disordered. It is important 
note the character and the seat of pain. It must not be forgotten that we 
meet with many instances of pa i n quite remote from the seat of the trouble 
which produces it, i.e., children frequently complain of pain in the abdomen 
in pneumonia or pleurisy. 

Pain i n joints and muscles is easily made out on motion and is as readily 
simulated. I am in vomiting and defecation and urination or coughing is 
dually characteristic owing to posture and expression. The hydrocephalic 
cry ,s characteristic. Intestinal, renal, biliary, and appendicular colic, gastro- 
intestinal neuroses and crises, and pains from intestinal worms and pelvic 
adhesions are no. always easily distinguished from one another. The agoni- 



REGIONAL EXAMINATION 



15 



zing pain of angina pectoris is characteristic. Pain in the region of the heart 
or kidney is usually muscular. When children have pain in the ear they 
hold their hand to the affected side and the head is held in a strained position 
on account of indurated and painful lymph nodes behind the ear. 

Certain forms of disease have characteristic points of pain on pressure, 
which are mentioned elsewhere. 

The diagnostic import of the seat of pain can not be scheduled, but its 
exact location is very important in diagnosis. Headache is a symptom of 
multiple origin and deserves special mention. A localized neuralgic headache 
or pain is frequently of malarial origin, but may also be due to local irritation. 
A dull general headache and coated tongue are generally due to indigestion. 
Headache may be of reflex character and take its origin in any disturbance 
of the bodily functions — circulatory, digestive, respiratory, eliminative, or 
excretory. It may accompany acute and chronic infection or take its origin 
in the nervous system — from fright, in injury, from hunger or fatigue, from 
eye strain, from disease of the sexual organs, from nasal irritation, from bad 
teeth, or from anaemia or hysteria. Persons who live in overheated and ill 
ventilated rooms are subject to headache. 

In parccsihesia there are subjective sensations such as formication, itching, 
bearing down, numbness, burning, cold and heat, girdle sensation, praecordial 
tightness and constriction, which will be discussed in their relation to special 
diseases. 

The Preliminary Examination of the Urine and Blood. — After eliciting 
and grouping the symptoms in a given case of illness, we are ready to proceed 
with the special or regional examination in order to ascertain whether we have 
to deal with a structural or functional disturbance. 

Before we begin our regional examination we should, if circumstances 
will allow, make a preliminary examination of the urine. This is of the utmost 
clinical importance. A qualitative examination of the urine for albumin, 
sugar, and bile can be made in five minutes, and the knowledge it imparts is 
like a guide post at a cross road — it points in the direction of a correct 
diagnosis. 

A preliminary examination of the blood for Plasmodium malarice in febrile 
disease is also important and enables us to inaugurate specific treatment if 
necessary without much temporizing. Whenever a blood examination can 
not be made immediately in a suspected case of " malaria " we may with ad- 
vantage send out a " diagnostic feeler " in the shape of a brisk cathartic com- 
bined with quinine (the therapeutic test). 

REGIONAL EXAMINATION 

It is assumed that the practitioner and advanced student are familiar 
with physical diagnosis methods and with the employment of ordinary specula 
and instruments for regional examinations, the use of which can not be learned 
from books, without which knowledge no one is competent to make a regional 
examination. 

A REGIONAL EXAMINATION IS FACILITATED BY GROUPING THE REGIONS 
AND ORGANS IN CONFORMITY WITH MODERN SPECIALISM, AND BY BEARING 
IN MIND THAT WE MAY CONSTANTLY MEET WITH MALFORMATION, INJURIES, 



16 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



\M N WD CHRONIC INFECTIONS AND THEIR SEQUELAE, PARASITIC INVASION, 
\\|. w I ^LIMITED NUMBER OF REFLEX NEUROSES AND INTOXICATIONS FROM 
WITHOUT OR FROM WITHIN (BY REASON OF FAULTY INTERNAL SECRETION). 

SPECIAL EXAMINATIONS 

Examinations with Rbntgen Rays are an established feature in medicine 
and surgery. X ray pictures, like all shadowgraphs, are apt to be deceptive 
and misleading. Stereoscopic or double ray prints are apt to give a clearer 
insighl into the actual relation of the parts than plain shadowgraphs. In 
making an x ray exposure, every precaution should be taken to avoid burns. 
In lengthy exposures the tube must be from ten to fourteen inches from the 
skin and the latter may be anointed with vaseline. 

Transillumination of organs and regions by means of condensed light 
occasionally gives definite results. 

The Tuberculin Test, which is of inestimable value in detecting bovine 
tuberculosis, may occasionally be employed; but in the present state of our 
knowledge the writer does not advocate its routine employment. See also 
article on Tuberculosis of Lungs. 

Exploratory Puncture and Incision are not performed often enough, and 
many a doubtful case could be readily cleared up by such a procedure under 
antiseptic precautions. 

Other Examinations, such as an examination of a patient in a comatose 
condition, are exl remely unsatisfactory as a rule. One should be very guarded 
in expressing an opinion in such cases, and emergency treatment is indicated 
without an exact knowledge of the underlying condition. See Coma. 

Finally, cases wall be met with in which the practitioner is compelled to 
anaesthetize the patient in order to clear up certain conditions. Hysterical 
contractures and stiff joints are thus detected, and a painful examination is 
made possible by the complete relaxation which anaesthesia affords. When 
anwsthesia is em-ployed for diagnostic purposes, the patient has a right to expect 
that the evidence to be elicited should be conclusive one way or the other. For 
laboratory findings, see following chapter. When a positive diagnosis has 
been made the line of treatment to be adopted is self-evident, and it should 
" carried ou1 on the principle of " non nocere." When the diagnosis is 
"in dubio," the treatment is naturally symptomatic. 



CHAPTER I— Concluded 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 

Synopsis: List of Apparatus and Chemicals. — Examination of Urine, Faeces and Entozoa, 
Gastric Contents, Sputum, Discharges, Exudates, Transudates, Puncture Fluids, Cyst 
Contents, Breast Milk, Cultures (Bacteria), Blood, Tissues, Calculi. — Drinking Water. 
— Remarks on Cytodiagnosis (cell diagnosis'), Cytolysis, Haemolysis, Cryoscopy. — Esti- 
mation of Renal Function by means of Phloridzin. — Directions for Preparing Spec- 
imens. 

INTRODUCTORY REMARKS 

The Laboratory is to the physician what the clearing house is to the busi- 
ness man. Laboratory work is necessary for correct diagnosis. The micro- 
scope shows a series of specific microorganisms, and also changes in tissues 
and blood. Pathological changes in the eliminative organs may often be 
inferred from a clinical examination of various secretions. 

While fine laboratory work is a specialty in itself, the general practitioner 
must avail himself of such laboratory facilities as are at his command. As a 
matter of expediency and convenience the gross analysis of urine, blood, spu- 
tum, and stomach contents can readily be made, as heretofore, in the office. 
The value of laboratory reports depends upon the time, care, and knowledge 
employed in making them. In important cases the knowledge and technique 
of the observer must be beyond question, and the clinician must rank foremost 
in the final adjustment of therapeutic measures. In acute illness, however, 
the proper management of suspected disease should not be delayed until a 
laboratory report is obtained. Many death certificates have been written in 
diphtheria cases because the practitioner waited for a laboratory report before 
giving antitoxine. 

EXAMINATION OF THE URINE 

APPARATUS 



Centrifuge. 

Measuring-glass— graduated. 

Urinometer. 

Test tubes. 

Litmus paper. 

Filter paper. 

Bunsen burner or alcohol lamp. 
Pipettes. 

Esbach's albuminometer. 
Slides, plain and hollow ground, and cover 
glasses. 

3 



Saccharometer. 

Doremus's apparatus for quantitative esti- ' 

mation of urea. 
Burettes, pipettes, flasks, beakers, funnels. 
Microscope, water bottle. 
Platinum wire inoculator. 
Graduated burette, with stand. 
Porcelain dishes. 

Tripod, with wire gauze for heating. 
Thoma-Zeiss white blood cell pipette and 
counting chamber. 

17 



is 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



CHEMICALS 



Bottle No. 2. 



Nitric acid. 
Nitric acid— fuming. 
An tic acid, 2 per cent. 
Acetic acid, glacial. 

Fehling's reagents. (Purchase ready made.) 
Cupric sulphate. Bottle No. 1. 
Rochclle salt. } 
Sodic hydrate. S 

Nylander's solution : 

Bismuth subnitr 2 parts 

Rochelle salts 4 parts 

Sodium hydrate (stick) 8 parts 

Distilled water 100 parts 

Stain for tubercle bacilli (Ziehl-Neelsen so- 
lution). 

Fuchsin sat. alcoh. sol 1.0 

Carbolic acid, 5 per cent aq. sol., 9.0 
Loeffler's solution: 

Methylene blue sat. alcoh. sol.. . 30.0 
Caustic potash, aqueous sol., 

1-10,000 100.0 



Silver nitrate solution, 5 per cent. 
Sodium hydrate sol., 40 per cent, and dec- 

inormal sol. 
Eosin solution, alcoholic, 1 per cent. 
Bromine, saturated aqueous solution. 
Potassium hydrate sol., 5 per cent. 
Hydrochloric acid, OP. HC1. 
Ether. 

Chloroform, 30 per cent. 
Sodium hydrate. 
Potassium hydrate. 

Gentian violet solution (alcoholic), satu- 
rated sol. 

Ehrlich's diazo reagents. See page 24. 

Esbach's solution: 

Citric acid 20.0 

Picric acid 10.0 

Water 1,000.0 

Cupric sulphate sol., 2 per cent. 

Five per cent ferric chloride. 

Iodine. Congo red. 



A complete outfit of apparatus and chemicals can be obtained from large drug firms. 



METHOD OF PROCEDURE IN EXAMINING URINE 

Color.— Wide variation in normal urine. Usually amber colored, light 
in- dark according to concentration. The presence of blood gives color from 
carmine to jet black, depending upon amount and upon changes which it 
may have undergone. Bile gives the urine color from greenish yellow to 
greenish brown. Chyle occasionally found in urine makes it milky. Poison- 
i 1 1 lt from carbolic acid and its related drugs makes urine often smoky or black. 
ScUol has been observed to make urine green. Rhubarb and senna may give 
a brown or deep red color. Methylene blue makes urine a greenish blue. 

Odor. — Similar to odor of bouillon; more often it is aromatic. When 
undergoing fermentation or decomposition, it has an odor peculiar to itself — 
the so called "urinous odor," more often foetid and frequently ammoniacal. 

Turbidity. — May be due to urates, phosphates, pus, epithelium, bacteria, 
casts, and chyle in suspension. Persistent turbidity is almost always due to 
pus, mosl frequently it is due to bacteria; when due to pus alone, the urine 
becomes clear on standing, a greater or less abundant sediment being de- 
Elongated needles of monohydrated magnesium phosphates are 
sometimes found in the urine of persons who have taken magnesia in- 
ternally. Phosphates are precipitated by heat and dissolve on the addition 
of nitrir acid. 

Consistence. — Usually fluid. Sometimes presence of pus and mucus 
nndcr it thick and viscid. In chyluria the urine often coagulates. 

Reaction.— Normally acid, intensely so in fevers and in certain diseases 
nf the stomach where HC1 secretion is diminished; in gout, lithaemia, 
acute articular rheumatism, chronic Bright's disease, diabetes, scurvy, leu- 
caemia, etc. 



CHEMICAL TESTS 



19 



Alkaline urine may exist under normal conditions immediately after the 
ingestion of a large amount of food or fruits. Persistent alkalinity indi- 
cates decomposition and usually cystitis. Some drugs — carbonates or or- 
ganic acids — may render the urine alkaline. 

Specific Gravity. — Determined by means of the urinometer and is very 
important, provided a twenty-four hour specimen is tested ; otherwise it is 
of questionable value. Persistent low specific gravity is frequently observed 
in neurotic people, and does not necessarily indicate a chronic nephritis. 
High specific gravity is observed in concentrated urines such as occur in fevers, 
in acute nephritis, and diabetes mellitus. In diabetes insipidus the urine has 
a low specific gravity. The term diabetes insipidus is a misnomer, because it 
has no connection with true diabetes. The mixture of the whole amount of 
urine passed in twenty-four hours must be had in order to make a correct 
determination of specific gravity. 

The amount voided in twenty-four hours is of importance. Normally, 
the average amount is from one to one and a half litres (40-50 oz.). Wide 
variations may exist in direct proportion to diet, weather, and nervous tension. 

Chemical Tests 

The urine should always be filtered before being tested. 

Albumin. — Heat and nitric acid test: Boil one or two drachms of filtered 
urine in a test tube. If albumin is present a precipitate appears, insoluble in 
a few drops of nitric or acetic acid. Earthy phosphates are also precipitated 
by heat, but these dissolve on the addition of nitric or acetic acid. 

Picric acid test ; Overlay a small quantity of urine by a saturated watery 
solution of picric acid. If albumin is present, a deposit, insoluble on boiling, 
forms at the line of junction. 

For an approximate quantitative test use Esbach's albuminometer. 

A large quantity of albumin in urine sometimes causes the urine in the 
test-tube to solidify upon boiling. Albumin is at times present in urine 
physiologically; this is called paroxysmal (cyclic) albuminuria. A highly 
albuminous diet (e. g., eggs) may cause albumin to appear in the urine. After 
severe exertion it is often found ; and sometimes it may persist in small 
amounts in the absence of apparent disease of the kidneys. The diseased 
kidney usually causes albumin to appear in the urine. All forms of acute and 
chronic nephritis may cause it to be excreted in considerable quantity. The 
amount depends upon the severity of the exudative process, the state of the 
blood, the venous congestion, and the condition of the capillary walls and 
renal epithelium. In chronic interstitial nephritis the albumin is low in 
amount and may frequently be absent for long periods. In periods of exa- 
cerbation, very large amounts may be excreted. In most febrile diseases, 
transient or continuous albuminuria may be observed and is referable either 
to an acute congestion and degeneration of the renal epithelium, or to an 
acute exudative nephritis. In typhoid fever, pneumonia, meningitis, ulcer- 
ative endocarditis, scarlatina, diphtheria, and smallpox, and all febrile dis- 
eases, also after convulsions, etc., traces are usually found. In yellow fever, 
it is often found twenty-four hours after the onset. It may occur in perni- 
cious malaria, and is nearly constant in cases of irritant poisoning. 



20 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



Peptone.— In the form of albumose, -peptone is found in the urine in many 
pathological conditions. It is most marked and constant when there is an 
accumulation with more or less absorption of pus in the body, as in empyema, 
cellulitis, suppurative meningitis, resolving pneumonia, and suppurating cavi- 
ties in phthisis; in ulcerative intestinal conditions, such as typhoid fever, 
tuberculosis, dysentery, and carcinoma. It also occurs in scurvy, pernicious 
ansemia, leucaemia, diphtheria, the exanthemata, acute yellow atrophy of 
the liver, pregnancy, and various nervous diseases (myelopathic albu- 
mosuria). 

For a differential diagnosis, the presence of albumose in urine may be 
of great value to distinguish: 1. Between suppurative and non-suppurative 
processes, especially tuberculous lesions. 2. Typhoid and other ulcerative 
intestinal lesions from catarrhal conditions. 3. Exanthemata, diphtheria, 
etc., from simple fevers. 

The general practitioner requires the aid of a laboratory expert to make 
these more delicate tests. 

Test', a. Separate completely ordinary albumin by boiling faintly acid 
urine. Filter. 

b. Take .50 c.c. of filtered urine, add 5 c.c. of concentrated HC1 to acidify. 
Then add 2 or 3 c.c. of 10 per cent phosphotungstic acid until precipitate 
ceases to form. 

c. Heat very carefully in a beaker over a wire-gauze flame until the pre- 
cipitate becomes an ashy gray resinous mass. The fluid is then decanted 
and the precipitate washed twice with distilled water to free it from acid. 

</. . \dil about 2 c.c. of distilled water and a few drops of 30 per cent 
solution of sodium hydrate to render it alkaline. Dissolve by gentle heat. 
If the solution is not colorless, add more alkali, drop by drop, while boil- 
ing. This fluid now contains a concentrated solution of albumose. The 
biurel tes1 is now employed by adding one drop of a very dilute solution 
of cupric sulphate. The presence of albumose gives a brilliant amethyst 
red color. 

Sugar is of significance in the diagnosis of diabetes mellitus. There 
is a transitory physiological glycosuria after the ingestion of a large amount 
of sugar, and traces are found when digestion is slightly disturbed. Disease 
of the pancreas and liver, some drugs, such as chloral hydrate, morphine, 
alcohol, and chloroform, may cause a slight transitory glycosuria. It is 
found sometimes during pregnancy, also in some nervous diseases, and in 
severe and fatal types of infectious diseases; also frequently after hysterical 
attack-, emotional excitement, and prolonged anesthesia. 

Ft rnu ntation Test : A small piece of ordinary compressed yeast is shaken 
with some of the suspected urine and a test tube filled with the mixture, 
to which some mercury is added. The tube is then inverted into a vessel 
containing mercury and allowed to stand in a warm place (70°-80° F.). 
If sugar be present, fermentation will occur in the course of twelve hours, 
and the carbon dioxide formed will rise to the top of the tube, gradually 
expelling more and more of the urine or the mercury as the amount of the 
gas increases. As the yeast itself, however, may give rise to the forma- 
tion of a little gas in the absence of sugar, as lactose, maltose, and levulose 
also undergo fermentation, and as the internal administration of mercuric 



CHEMICAL TESTS 



21 



chloride, iodoform, salicylic acid, quinine, and other antiseptic drugs may 
stop the fermentation, the test is of value only as a control-test. 
Precautions : 

1. Urine must be faintly acid. 

2. Urine should be diluted so that its specific gravity is approximately 
1008. Allowance must be made in result by multiplying by corresponding 
factors. 

3. Urine should not contain above 1 per cent glucose. 

Fehling's Test is probably most used. There are two solutions. Take 
equal parts of each solution in a test tube, and dilute once with water. Boil, 
add a few drops of urine, and boil again. Sugar gives a brick-red precipi- 
tate. Inasmuch as there are other organic compounds which precipitate 
the cupric sulphate in Fehling's solu- 
tion, a control fermentation test should 
be made; or, for a qualitative test, boil- 
ing with potassium hydrate solution 
seems to be preferable. Urine changes 
from canary yellow to dark brown, 
according to amount of sugar present 
if boiled with this solution. 

Quantitative Test : The quantitative 
test is important to ascertain whether 
the diet and treatment are diminish- 
ing the amount of sugar, even though 
the severity of the disease is not in 
proportion to the amount of sugar. 
Procedure : Remove albumin by precip- 
itating, after acidifying, boiling, and 
filtering the precipitate. Dilute the 
urine from one half to one fifth. Fill 
the graduated burette with the diluted 
urine. Dilute 5 c.c. of Fehling's solu- 
tion with 40 c.c. of water. Let it boil Fig. i.— Einhorn Saccharometeb. 
over a wire gauze frame. While boil- 
ing let diluted urine fall in, drop by drop. Remove the flask from the flame 
from time to time to allow the precipitate to settle, and to observe the color 
of the solution. When every particle of blue color has disappeared, read 
the amount of dilute urine used from burette. The amount of sugar can 
be estimated from this formula : 

y : .05 : : 100 : x grms. of glucose. 

y = number of c.c. of diluted urine used. 

x = grms. of glucose per 100 c.c. of diluted urine employed. 

Example: If 10 c.c. of urine diluted five times have been used, we have 
used 2 c.c. of urine. Hence, 2 : .05 :: 100 : answer = 2J. 

Why? Fehling's solution is of such composition that 10 c.c. requires for 
complete reduction .05 grm. of glucose. 

Acetone is found in the urine in severe forms of diabetes mellitus, after 
ether anaesthesia, and in those diseased conditions in which there is a high 




22 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



degree of albumin destruction, as in high fever, severe anaemias, many carci- 
nomas, acute active phthisis, and in disturbances of digestion. 

Tesi : Pour a few drops of a strong solution of sodium nitroprusside into 
a small amount of urine in a test tube, and make it markedly alkaline. At 
firsl a purplish red color appears, gradually turning to yellow. Add two to 
three drops of acetic acid. The presence of acetone gives a color ranging 
from carmine to a purplish red. 

Diacetic Acid and /?-Oxybutyric Acid are found in the urine in severe 
cases of diabetes mellitus. 

Test: Add strong ferric chloride solution to unboiled urine until all 
phosphates are precipitated, then add carefully a diluted ferric chloride 
solution. A Bordeaux red coloration of the urine indicates diacetic acid. 
This coloration will disappear on heating. 

The presence of /3-oxybutyric acid is detected by the polariscope 
after eliminating the sugar by fermentation. The ray of light is turned 
to the lejt. 

Bile.— Bile in the urine indicates some obstruction to its normal flow. 
It may be detected in the urine before other symptoms of jaundice develop. 

Tesi : [f about half an inch of fuming nitric acid be poured into a test 
tube ami a few drops of urine be allowed to float on the top, the presence of 
bile will give at line of contact a play of colors, red and green predominating. 
When the fuming nitric acid comes in contact with the urine and a brown or 
purplish ring forms without a play of color, it indicates the presence of indican. 

Indican. — The presence of an abnormal amount of indican in the urine 
indicate- a putrefaction of albumin somewhere in the body tissues or in the 
body-cavities, usually of bacterial origin. Indican is almost invariably 
formed in the intestinal tract (ileum) as the result of proteid putrefaction due 
to bacterial action, probably the colon bacillus.- 

Tesi : To 5 c.c. of concentrated hydrochloric acid and 5 c.c. of urine add 
four drops of a half per cent solution of potassium permanganate in water 
and 2 c.c. of chloroform. If the solution is blue after shaking, indican is 
present. The intensity of the color indicates the relative amount of indican 
in the wine. 

Mucus. The presence of mucus in the urine in abnormal amount indicates 
an inflammation along the urinary tract, generally a cystitis. 

Test: Noticed as cloudiness throughout the urine, which has been allowed 
to settle slightly. Under microscope it is seen as numerous shreds, clumps, 
or m i i hyaline in character. If urine containing a fair amount of mucus 
be acidified and boiled, wc get a cloudiness similar to that given by albumin. 

Haemoglobin.— The presence of small amounts of blood in the urine, or 
derivation from the red blood cells can be demonstrated by testing for 
hemoglobin, or its derivatives, with the polariscope. 

Color test : To a small amount of urine in a test tube, add one fourth its 
volume of caustic potash and boil. The earthy phosphates will be precipi- 
tated. The presence of blood gives the flocculent precipitate a reddish brown 
color, [f t he urine is much pigmented, as by bile in jaundice, the color will 
prevent the reaction. Also look for red blood cells with the microscope. 

Urea.— The normal amount of urea excreted in twenty-four hours is 
fro,,. 20 to ID !; rms . ( tf()_600 grains). The diagnosis of a chronic interstitial 



CHEMICAL TESTS 



23 



nephritis without exudation is made by the specific gravity and by estimating 
the amount of urea secreted in twenty-four hours. A specimen of urine from 
each of the amounts of urine passed in twenty-four hours should always be 
employed for examination. 

Test : Solution sodium hypobromite. 

1$ Sod. hydrate (30-per-cent sol.), 70 parts ; 

Bromine, 5 parts ; 

Water, 150 parts. 



z t 
- t 







As the solution keeps only a few days, it should be made fresh each time. 
The sodium hydrate solution and the bromine should be kept separate. 
Fill the apparatus so that when erect no air can enter the tube. The urine 
should be diluted once. This is not necessary unless the 
urine is very concentrated. Take 1 c.c. of urine in the 
pipette, immerse the tip under the bend in the appara- 
tus with great care so as not to allow air to enter, and 
discharge all of the 1 c.c. into apparatus by slowly press- 
ing the bulb of pipette. None of the air behind the 
column of urine should be pressed into the apparatus. 
Allow it to remain for one half hour. Then read 
amount of solution displaced. The number of milli- 
grams of urea marked on tube are displaced by 1 c.c. 
of diluted urine. It is a simple calculation to find the 
total quantity of urea for twenty-four hours in a 
twenty-four-hours' undiluted urine. 

Chlorides. — An increase or decrease of chlorides in 
the urine is of importance. They are increased in poly- 
uria and during absorption of inflammatory fluids. 
They are decreased in starvation or lack of food, in 
vomiting, where little absorption of food takes place, 
in diarrhoea, where there is a serous discharge, and in 
inflammatory exudative processes, particularly where 
there are purulent exudations. This is the most important cause for the de- 
crease in the amount of chlorides. The test for chlorides is indirectly a test 
for purulent inflammations, such as pyaemia, and in pneumonia. The latter 
disease in some of its phases at times simulates typhoid or malaria. The 
very small amount of chlorides excreted in pneumonia may be of differential 
diagnostic value. Indeed, it is said that the prognosis in pneumonia may be 
determined by the amount of chlorides in urine, as in fatal cases there is almost 
a complete absence of these constituents. There is frequently a slight decrease 
several hours before the crisis in pneumonia, before there is any clinical change. 

Test : Remove albumin by precipitating it by boiling the slightly acidu- 
lated urine and filtering. Take an inch of filtered urine in a narrow test tube, 
cool and acidify with one or two drops of concentrated nitric acid. Add one 
drop of a 5 per cent solution of silver nitrate. A white precipitate is formed 
of silver chloride. 

Quantitative Test for Chlorides : Take 5 c.c. urine, diluted so as to sub- 
due the color. Titrate with decinormal silver nitrate solution, using yellow 
potassium chromate as indicator. End reaction is reached when the orange 




Fig 



Ureometer. 



24 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



rec | color Erst becomes permanent. The amount of chlorides may then be 
determined from amount of silver nitrate requisite. 

Diazo Reaction.— This is supposed to be of value in the diagnosis of 
typhoid fever, but it may be absent in many cases. It is present in the worst 
(usually fatal) cases of tuberculosis. 

Test : This test requires two solutions : 



No. 1. Sulpharrilic acid, 1.0 

Concentrated hydrochloric acid, 50.0 

Water, 1,000.0 

No. 2. Sodium nitrite, 5.0 

Water enough to make, 1,000.0 



Take ."> c.c. of urine in a narrow tube, add 5 c.c. of solution No. 1, then 
add three drops of solution No. 2. Float 2 c.c. of ammonia on top. At the 
point of ( (intact a deep garnet ring will appear and a salmonpink foam on 
shaking. 

Haematoporphyrin, a hamiatin derivative, is found in traces in all urines, 
as well as in feces. Increased amounts in the urine seem to suggest hepatic 
insufficiency. In addition to its having been found in the urine of cases of 
various forms of hepatic disease, hcematoporphyrinuria has been observed 
in cases of phi hisis, exophthalmic goitre, typhoid fever. It is also often found 
in intestinal and gastric haemorrhages, in lead poisoning and especially after 
long continued use of sulphonal, trional, and tetronal. Urines containing an 
excess of haematoporphyrin are usually dark red in color; but the shade may 
vary from a sherry or port wine tint to a dark Bordeaux. 

'/'< si I Sinn m ) : Thirty c.c. of urine are treated with an alkaline solution of 
barium chloride. The precipitate, after having been washed with water, and 
then with absolute alcohol, is extracted with ordinary alcohol, acidulated 
with hydrochloric acid, by rubbing in a mortar. The solution thus obtained 
will presenl a reddish color in the presence of haematoporphyrin, and its fil- 
irate yield- the characteristic spectrum of the latter substance, i.e., four 
bands of absorption, of which two are broad and dark and two light and 
narrow. The former alone are characteristic, and frequently the only ones 
visible. ( >ne of these extends beyond D into the red portion of the spectrum, 
while the other is situated between B and F of the other two bands. One 
may be seen between C and D, and the other between D and E, nearer E. 

Microscopical Examination of Urine 

Casts, fhe e are cylindrical, albuminous bodies derived from blood 
aerum and take their shape from the uriniferous tubules below the loops of 
The differenl varieties receive their names from their consistency 
and contents. 

—Homogeneous, transparent, cylindrical, broader than a 
leucocyte but often much narrower. Their length varies. The border is 
delicate, distinct, and not refracting. The ends are rounded. They are 
found in a large- per cent of centrifuged urine, and of themselves are of no 



MICROSCOPICAL EXAMINATION OF URINE 



25 



diagnostic value, but are always abnormal, i. e., they are not a normal con- 
stituent of urine. They are more common in the urine of old persons and in 
people suffering from chronic diseases ; also after many conditions causing 
temporary ailments. They are abundant in chronic nephritis in children and 
adults. 

Waxy casts usually indicate an amyloid change in the kidney. They 
are stained a mahogany color by iodine in acid solution. They are usually 
broader than hyaline casts, the edges are sharp, and they are less transparent, 
most frequently opaque. They are found in chronic nephritis, particularly 
amyloid and chronic parenchymatous changes. Their presence is against the 
diagnosis of acute nephritis. 

Granular casts. — a. Finely granular — a hyaline body covered or mixed 
with fine granules of urates. They are of no more importance than hyaline 
casts, but excite suspicion, b. Coarsely granular — are found by the breaking 
down of the bodies of epithelial cells. There may be a little hyaline substance 
in the body, but the granules usually are so thick as to give the casts the ap- 
pearance of being opaque and yellow. Shreds of epithelial cells may be seen. 
They are of considerable significance and indicate a chronic nephritis or an 
acute exacerbation of a chronic nephritis. It may be some weeks or months 
after an attack before they are found. In centrifuged urine, hyaline casts 
studded with urinary salts present the appearance of granular casts. This 
is not ordinarily the case in gravity sediment, i. e., sediment formed on 
standing. 

Epithelial casts are formed of intact or broken-up epithelial cells. They 
are yellowish, large, broad, opaque, with regular edges, and may or may not 
have a hyaline matrix. All gradations between coarsely granular and epithe- 
lial casts occur. They signify an acute nephritis or an exacerbation of a 
chronic nephritis, and are frequently found in chronic nephritis. 

Pus casts are made up of leucocytes, and are to be differentiated from 
epithelial casts by: (a) Their transparency, (b) their lighter color, (c) the 
absence of characteristic structure. Their presence indicates an acute in- 
fectious exudative nephritis. A purulent nephritis also has pus casts, but 
there are also many cells free in the urine. 

Blood casts are casts packed with red blood cells. Significance : Acute 
nephritis or an acute exacerbation of a chronic nephritis or traumatism. 

Bodies resembling Casts. — Masses of Urates. — The outline is ragged 
instead of defined ; edges are dark instead of yellow or transparent. 

Cylindroids from urine of cystitis are differentiated by non-uniformity 
in size and shape. They have the same significance as hyaline casts. 

Blood in Urine. — If blood be not diagnosed grossly, it can be recognized 
with the microscope. In the urine, it may come from any portion of the 
genitourinary tract. (See Hematuria.) 

Aloin Test for Blood. — One fifth volume of glacial acetic acid is added to 
suspected material and allowed to stand one half hour. Sulphuric ether, 
one third volume, is then added and allowed to stand one half hour. The 
ethereal extract is decanted into small test tube. A few grains of aloin are 
added. Peroxide of hydrogen or other oxidizing agent is then added, of 
volume equal to that of ethereal extract. A cherry red color indicates 
blood. This test can be used for urine, faeces and stomach contents. 



26 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



Pus in Urine— Pus is readily recognized in urine by means of the micro- 
3CO pe. [t also may come from any portion of the genitourinary tract. If 
dated with pus casts, it probably comes from the kidneys. Pus from 
kidney in pyelitis is said to occur in little masses composed of six to eight or 
more leucocytes closely packed together. (See Pyuria.) 

Pits : Add strong KOH to urine. Pour from one beaker to an- 
other several times. The formation of a tenaceous stringy mass is indi- 
cative of pus. 

Epithelium.— This is readily seen and recognized under the microscope, but 
the differentiation in cells from different parts of the genitourinary tract is 
very difficult and requires much experience. The cells from the pelvis of 
kidney are columnar and sometimes round or polygonal, and similar cells are 
found in follicles of the prostate gland. Bladder cells are broader and shorter. 
Large, flat, squamous epithelial cells from the vagina are found normally in 
urine from the female. 

Spermatozoa. — These are found often in urine of both the female and male 
after coitus, and after a seminal emission. If a urine constantly contains 
spermatozoa, this is an indication of spermatorrhoea. 

Gonococci. — Gonorrhceal threads can be found in urine by having patient 
urinai e in two glasses, and holding the first up to the light, when mucoid 
particles can be seen floating in the fluid. To find the gonococci, it is best 
to take a drop of pus or mucus from urethra and stain as described under 
I lischarges. They can often be found only in the shreds. 

Tubercle Bacilli. — The tubercle bacillus can often be found in urine which 
has been centrifuged and also frequently in gravity sediment. It closely 
bles t tie smegma bacillus and the similarity in their staining properties 
demands decolorization in pure alcohol for about twelve hours. The smegma 
bacillus is decolorized by this treatment. If the urine is carefully drawn 
with a catheter, the smegma bacillus can often be excluded. 

Typhoid Bacilli. — This bacillus is almost constantly found in the urine of 
typhoid-fever patients, and is demonstrated by making cultures. Other 

misms found in t he urine are the Micrococcus urea?, the different pus cocci, 
actinomycosis granules, yeast cells and mold, colon bacillus, several forms 
of proteus, Staphylococcus aureus and sometimes the streptococcus. 

Parasites in Urine.- A few parasites have been found. The trichomonas, 
amebae, ova of the distoma haematobium, and the larvae of Filaria sanguinis 
ho minis. 

Inorganic elements are always found in urine. If the urine is acid, we 
may find crystals of uric acid, urates, and calcium oxalate, or neutral calcium 
phosphate, tf the urine is alkaline, we may find crystals of triple phosphate, 
calcium phosphate, carbonates and ammonium urates and calcium oxalate, 
and magnesium phosphate. Leucin and tyrosin are found in the urine in 
poisoning by phosphoric acid, in acute yellow atrophy of the liver, and in 
severe cases of typhus fever and smallpox. 

Test'. Evaporate the urine to consistency of syrup and examine under 
microscope for characteristic crystals. 



EXAMINATION OF FAECES 



27 



EXAMINATION OF FAECES 

CHARACTERISTICS 

Number of Stools. — The normal number is one stool a day. Three in 
one day or one in forty-eight hours may not be an indication of a pathological 
condition. 

Reaction whether acid or alkaline is not significant. 

Amount. — The amount varies in proportion to the solids ingested. The 
average is 60 to 250 grams in twenty-four hours, of which about 75 per cent 
is water. 

Consistence. — The consistence varies from the watery discharges in cholera, 
to the hard, scybalous masses of chronic constipation, and depends largely 
upon the amount of fluids ingested and the condition of the digestive tract. 

Odor. — The natural offensive odor of faeces is due to albuminous decom- 
position and the resulting principles : indol, skatol, phenol, ammonia, fatty 
acids, hydrogen sulphide, etc. Some odors are characteristic, such as those 
of fatty diarrhoea in children, some alcoholic stools, in chorea and in amebic 
dysentery. 

Color. — The normal color varies according to the character of the food 
and the amount of pigment derived from bile. In infants, fat and undigested 
milk gives to the stools a whitish color tinged with bile pigments. In adults 
the color is usually brownish yellow. 

Green stools are seen after taking calomel and on exposure to air. Such 
stools are usually acid. 

Black or very dark stools may be due to a meat diet, huckleberries, red 
wines, iron, manganese, and bismuth. Many stools containing old blood are 
dark or black. 

Yellow stools may be caused by the ingestion of santonin, rhubarb, and 
senna. Typhoid stools are yellowish, having received the name of " pea soup 
stools." 

White or clay colored stools are due to alcoholic conditions in which there 
is an obstructive jaundice. 

The Gmelin reaction for bile (the play of colors when the fluid being treated 
comes in contact with fuming nitric acid) is not found in normal stools. If 
found, it indicates disturbance in the small bowel (active intestinal catarrh 
in children). The presence of leucocytes, epithelial cells, mucus, and bacteria 
give the whitish, so-called " rice water" stools. Rupture of an abscess gives 
a whitish or yellowish stool (pus). 

Much recognizable detritus may be observed in stools. This is composed 
principally of imperfectly masticated or accidentally swallowed vegetable 
products, such as orange cells and strings of spaghetti, which are sometimes 
mistaken for parasites. Glittering white deposits or streaks are composed 
of long crystals of fat derivatives. 

Foreign bodies of nearly every description, and gall stones, are found by 
passing fluid faeces through a sieve. Greasy, translucent, jagged calculi are 
due to the crystallization of cholesterin ; dark brown, heavy, and hard 
calculi may be formed in the intestines and passed in the faeces. Calculi 
containing calcium salts are opaque, usually light colored, brittle, and have 
rough granular surfaces. 



2 s 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



Mucus in different forms, according to the portion of the intestines 
where it is secreted, is often found in the faeces. If abundantly formed in the 
small intestine and upper colon, it is well mixed with bile pigment, epithelial 
cells, leucocytes, and food detritus. In colitis, mucous masses are well sepa- 
rated from i be other constituents. In inflammatory conditions of the rectum, 
discrete masses of mucus may be adherent to the surface of the stool. 

Casts of pari of the intestinal tract, or cylinders of thick, white mucus 
resembling fibrin are diagnostic of membranous enteritis. These mucous 
masses are from several inches to a foot in length and may be spirally twisted 
or ribbon shaped. They often resemble a tapeworm, for which they have 
sometimes been mistaken, and are of the consistence of jelly. 

Pus often occurs in faeces from rupture of a tubal or supravaginal abscess 
or from appendicitis. In ulcerative colitis or carcinoma of the rectum much 
pus is seen in the dejecta. 

Blood in the stool differs in appearance according to the location in the 
digestive trad from which it comes. When from the stomach, the action of 
i he gasl ric digestion causes it to appear in the form of fine granules, giving a 
grayish black color to the stool. Rarely, gastric blood gives a tarry stool. 
Tarry stools with some lumps of blood undissolved, may occur in duodenal 
ulcer. Ulcers of the ileum are usually attended by stools of pure blood, 
or by blood well mixed with the faeces, retaining more or less its red color. 
From an ulcerative colitis, red blood cells are nearly always found in shreds 
of mucus which are blood stained. In haemorrhages from the colon, if large, 
and from the rectum the blood is very little changed. 



MICROSCOPICAL EXAMINATION OF FyECES 

Muscle Fibres. — These are found with striations preserved or reduced to 
colorless, homogeneous, translucent, oval or elliptical bodies. Starch grains 
usually appear as coarse, refractive bodies which turn blue or brown when 
treated with diluted nitric acid and Gram's solution. 

Fat may be seen as fat globules, in crystalline forms, or in cholesterin 
plates. Normal stools nearly always contain some fat, but strictly speaking, 
this ""' ;| fat, but when present in large quantities it often indicates a 
diminished production of pancreatic juice and bile, and is characteristic of 
some acute and chronic diseases of the small intestine. 

Coagulated protcids, vegetable cells, and diatoms are often noticeable in 
the stools. Pus cells more often indicate an ulcerative process than a simple 
Blood cells can frequently be found when a gross inspection of the 
Btool fails to reveal the presence of blood. Epithelial cells in the stools may 
often be of greal importance. A few may be found in normal stools, but in 
catarrhal conditions they are very abundant. In cholera the stools are 
largely composed of serum, epithelium, leucocytes, and bacteria. 

In typhoid ulcers, epithelial cells and shreds of necrosing tissues may be 
found. A diagnosis between catarrhal and ulcerative processes may be made 
by finding clumps of epithelial cells, adherent leucocytes, and blood cells in 



in water 



1 The solid contents of faeces can be collected by means of a flour sifter rotating 



MICROSCOPICAL EXAMINATION OF FAECES 



29 



the masses of mucus discharged from ulcers. Shreds of malignant new growths, 
with their atypical cells, can help in diagnosis. 

Crystals of the fatty acids are very frequent, and cholesterin occasionally. 
They seem to be of no significance. Charcot-Leyden crystals are sometimes 




Fig. 3. — Scolex and Segments of Taenia Saginata. 



found in abundance and are said to be present in the faeces in people who are 
known to have intestinal parasites. 

Calcium oxalate, sulphate, and phosphate are found, especially after a 
vegetable diet. Triple phosphates also are found very often, and are associated 
with alkaline diarrhozal stools. Bismuth gives typical black crystals, and altered 
blood gives hcematoidin crystals of a brownish-red color. 

Bacteria and Protozoa in Faeces. — There are many microorganisms in 
the intestinal tract, some of which ordinarily are harmless, but under certain 
conditions become pathogenic. Some are 
distinctly harmful and seem to cause the \^fU 
diseased conditions. 

The Bacillus coli communis is con- 
stantly present in the fasces from all parts 
of the intestine in health as well as in 
disease. It has been found exclusively 
in cases of appendicitis, peritonitis, em- 
pyema of the gall bladder, nephritis, 
pyelitis, cystitis, and occasionally in 
pyosalpinx. 

The Bacillus lactis aerogenes and the 
Proteus vidgaris (also found normally) are Fig. 4. — T^nia Solium. 

present in many cases of cholera infan- 
tum. The distinctly pathological bacteria of fasces are the Bacillus typho- 
sus in typhoid fever, which can be isolated by plate-culture during the first 
few days of the fever; the Comma bacillus present in Asiatic cholera; the 
Streptococcus pyogenes which is probably the etiological factor in some forms 
of enterocolitis; the Bacillus dysentericus (Shiga bacillus), and the tubercle 




30 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



bacillus. The Ameba dysenteric is very probably the specific germ of one form 
of colitis, particularly that type associated with hepatic abscess. They so 
much resemble an epithelial cell that an absolute diagnosis 
can be made only by seeing them moving under the micro- 
scope. In order to keep them alive long enough for 
examination, the defalcation must be received in a warm 
pan, and the slide must be warmed. The question as to 
the pathognomonic relation of ameba to diarrhoea is by 
some still considered an open one. 

WORMS 

Taenia solium, or pork tapeworm, is not uncommon. 
The head is provided with hooklets. Taenia saginata, or 
beef tapeworm, is the 
one usually seen. 
Bothriocephalus I a - 
tus, or the fish tape- 
worm, is rare in this 
country. The head 
is not provided with 
hooklets. Taenia echi- 
nococcus, although 
living in the intesti- 
nal tract of the dog, 
may enter man by 




F I O . 5. T JE N I A 

Echi NOCOCCUS. 
Magnified 20 dia- 
meters. (Braun.) 




Fig. 6. — Contents of an Echinococcus 
Cyst showing Scolices, Hooklets, 
and cholestekin crystals. 



means of its eggs, 
and produce cysts, particularly in the liver. 



The head is covered with 
ilM| ' 1 Wets which, if separately found, are diagnostic of its presence. 




CLINICAL EXAMINATION OF THE STOMACH CONTENTS 



3 J 



The Nematodes. — Ascaris lumbricoides, or roundworm, is common in chil- 
dren. It measures from six to sixteen inches in length and may wander all 
along the intestinal tract and produce indefinite nervous symptoms. Oxy- 
uris vcrmicularis , thread or pinworms, are found in the lower ileum, colon, 
and rectum. They may cause intense pruritus. Anchylostomum duodenale 
and the Trichocephalus dispar s. hominis are also found, and are supposed to 
produce profound anaemia. 

Although the chemical examination of the faeces is important, our present 
knowledge is not sufficient for it to be of much clinical significance. 



CLINICAL EXAMINATION OF THE STOMACH CONTENTS 



APPARATUS 

Stomach tube. 
Three beakers. 
Long c.c. pipette. 
Porcelain evaporating dish. 
Litmus paper. 

Titrating apparatus : a graduated pipette on a stand with a stopcock at 
the base permitting the flow of the decinormal solution drop by drop. 

CHEMICALS 

Solution phloroglucin vanillin. (Giinzberg's Test.) 

Py Phloroglucin, 2 parts; 

Vanillin, 1 " ; 

Absolute alcohol, 30 " . 



FLUIDS REQUIRED FOR GETTING THE TOTAL HYDROCHLORIC ACID IN 
STOMACH CONTENTS 

1. Amidobenzol, 5 per cent alcoholic solution. 

2. Alizarin, 1 per cent aqueous solution. 

3. Phenolphthalein, 1 per cent alcoholic solution. 

4. Three beakers, each containing 5 c.c. of filtered stomach-contents 
and each diluted with an equal quantity of distilled water. 

5. Decinormal solution of sodium hydrate. 

Method of preparing a decinormal NaOH solution : Dissolve 63 grms. of 
oxalic acid C. P. (accurately weighed) in distilled water, bringing the solution 
up to one liter at a temperature of 60° F. (15° C). Dissolve about 40 grms. 
NaOH (C. P.) in distilled water and bring the solution up to one liter. 

Place 10 c.c. oxalic-acid solution in a beaker, add one drop of phenol- 
phthalein, and titrate from a burette with the soda solution. 

If it takes 9.5 c.c. of the soda solution to neutralize 10 c.c. of oxalic acid, 
5 c.c. of water must be added to each 9.5 c.c. of the soda solution to render 
it of the standard normal strength, and to 950 c.c. of soda solution 50 c.c. 
of water must be added. Water may readily be added in whatever proportion 



32 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



is found necessary. Nine parts of water added then to one part of the normal 
gives the decinormal solution. (Ewing.) 

Gross Appearance.— Food products in early stages of digestion, such as 
milk curds, particles of meat, vegetable detritus, are readily recognized by 

the naked eye. . 

Mucus appears in nearly all vomitus as thin, translucent, stringy masses. 
In chronic gastritis more opaque mucus and more uniformly mixed with 
food is found. Blood is sometimes streaked, clear, and unchanged through 
vomitus in acute gastritis. Fresh blood is seldom seen in vomitus, as its 
presence in the stomach for only a few minutes changes it to a dark brown 
color. This is not true of the larger haemorrhages, as from the rupture of 

a |,| i vessel. The usual vomitus from an ulcerating carcinoma resembles 

coffee grounds in form and color. 

Where pyloric obstruction and dilatation of the stomach exist, large quan- 
tities of a blackish fluid may be vomited, the color of which is due to old and 
greatly altered blood. Bile frequently discolors the vomitus, especially after 
long straining at emesis, giving a color from yellowish to greenish. Pus, 
from rupt ureof a neighboring abscess, may appear in large quantities. Fwcal 
i, mi:, r appears when there is intestinal obstruction. Roundworms are rather 
frequently seen in vomitus, and Oxyuris vermicularis and Anchylostoma duo- 
denale very rarely. 

MICROSCOPICAL EXAMINATION 

The following may be looked for: 

Muscle fibres with striations as oval, elliptical, yellowish or colorless, 
slightly refractive bodies; a great variety of vegetable cells and starch grains, 
with concentric layers and reacting to iodine; fat in globules or as crystals; 

lil 1 in cells, as haematoidin, or as masses of pigment; leucocytes, recognized 

by their opaque granules and small refractive polymorphous or multiple 
nuclei; t pithcli inn , columnar from stomach and squamous from oesophagus 
and mouth, found in the masses of mucus. In acute gastritis, epithelium 
may be very abundant. Particles of mucous membrane in chronic gastritis 
and shreds of tissue from ulcerating carcinoma may often be found after 
can Mil search. Yeast occurs in groups of three or more round or elliptical 
refractive bodies about the size of red blood cells. They frequently show 

i ral -mail Minis. Sarcinee are cocci growing in cuboidal packets of eight 
individuals or multiples of eight. Bacillus acid lactici, connected with fer- 
ment a i ion. and the Streptococcus pyogenes, associated with some infectious 
cases of acute gastritis, have been isolated. The Oppler-Boas bacillus is 
found in stagnating stomach contents free from hydrochloric acid and not 
rich in lactic acid. By some authorities it is considered of diagnostic value 
in carcinoma of I he stomach. 



CHEMICAL ANALYSIS 

I vald'stesl breakfast is generally used. It consists of 30 to 70 grammes 
< - M . oz.) of white bread and 10 oz. of water. The test meal is to be given in 
the morning on an empt y stomach. If there be retention of food, the stomach 
is to be washed out the evening before. One hour after eating the test meal, 



CHEMICAL ANALYSIS OF STOMACH CONTENTS 



33 



the contents of the stomach should be expressed or siphoned off. To the 
filtered contents the following tests should be applied: 

Acidity, by litmus or Congo red paper. Free hydrochloric acid by Ginz- 
berg's reagent. The reagent is thinly spread and evaporated over a clean 
porcelain dish. A few drops of the stomach contents are added and the dish 
gently heated over the flame. If there is free hydrochloric acid, a carmine- 
red color appears along the edge of contact of the stomach fluid. 

Combined HC1 and total amount HC1. The method of obtaining total 
productions of hydrochloric acid is based upon the sensitiveness of certain 
coloring reagents to the various acid principles found in stomach contents. 

(a) Dimethylamidoazobenzol (or Toepfer's reagent) reacts only to free 
inorganic acids, such as free hydrochloric acid. 

(6) Alizarin reacts to : 

Organic acids (lactic, butyric, etc.). 
Acid salts. 

Free, but not loosely combined HC1. 
(c) Phenol phthalein reacts to: 
Organic acids. 
Acid salts. 
Free HC1. 
Combined HC1. 

It has been found that 1 c.c. of decinormal soda solution neutralizes 
.00365 gramme of HC1. If 5 c.c. of decinormal soda solution are required 
to produce the final reaction with amidobenzol, the fluid contains 5 times 
.00365 grammes of free hydrochloric acid. 

The combined hydrochloric acid may be found by subtracting the quan- 
tity required in the second titration (with alizarin) from that required in the 
third (with phenolphthalein) ; for, by consulting the foregoing lists, it will 
be seen that: 

6 — & = the combined hydrochloric acid. 

Hence, as a working formula, we may take the following: 
Titration to get a = free HC1. 
" " c = total acidity. 

" " 6 = inorganic acidity (all acidity except combined 

HC1). 

Total acidity c, minus inorganic acidity 6 = combined HC1, which, united 
to a (the free HC1) gives the total production of hydrochloric acid. 

.Method of Procedure : To one beaker, containing 5 c.c. of filtered 
stomach contents, diluted once, add one to two drops of amidoazobenzol 
solution, which, in the presence of HC1, immediately turns a bright red color. 
From the graduated burette decinormal soda solution is carefully added until, 
upon agitating the beaker, the fluid begins to turn to an orange yellow color. 
Soda solution is further added, drop by drop, until all traces of red have dis- 
appeared and the fluid is a bright lemon color, which indicates the final re- 
action. The quantity of soda solution used is noted, from which is computed 
the amount of free hydrochloric acid present. 

To the second beaker, one to two drops of alizarin solution are added, and 
the titration conducted as above. The final reaction is indicated when a deep 
4 



34 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



violel color is reached. From the amount of soda solution used may be 
cmiputiMl the acidity due to all acid principles except loosely combined HC1. 

rp the third beaker, one to two drops of phenolphthalein solution are 
added and il is titrated as before. The final reaction is indicated when the 
I appearing no longer darkens on further addition of soda solu- 
tion. From the amount of soda solution used the total acidity is computed. 

Significance of Changes in the Amount of HC1 in Stomach. — If the normal 
amount is found (.1 per cent to .2 per cent), it is strong evidence against 
any organic disease of the stomach. The symptoms referred to the stomach 
u h eil a normal amount of HC1 is present must be due either to a nervous or 
atonic condition. Continuous hyperacidity (over .2 per cent) occurs most 
frequently in neurotic dyspepsia, is very often present in simple ulcer, and 
may often be a symptom of the early stages of a chronic gastritis. It speaks 
strongly againsl carcinoma except when a simple ulcer is undergoing car- 
cinomatous transformation. Continuous subacidity (under .1 per cent) is 
seen in chronic gastritis, especially with dilatation and atony, in some cases 
of simple ulcer with chronic gastritis, and in incipient carcinoma. Anacidity 
is a frequent and persistent symptom of the later stages of chronic gastritis, 
when pepsin is also lacking. When pepsin is present, it may indicate a neu- 
rosis. When other signs are favorable, it speaks strongly for carcinoma. If 
the amount of acidity due to HC1 varies markedly, in all probability it indi- 
cates a neurosis. 

Lactic Acid. — The test for lactic acid usually employed is Uffelmann's. 
Although there are sources of error, this test is fairly reliable. Test: Take 
Hi c.c. of a .") per cent solution of carbolic acid; add 20 c.c. of distilled water, 
and one drop of a 5 per cent solution of ferric chloride. An ametlvyst blue 
color appears, which may soon change, making it imperative to use the solu- 
tion hen fresh. A few drops of the stomach contents added to this solution 
produces a lemon color if lactic acid be present. 

Significance of Lactic Acid. — It is often ingested with food, and forms 
early in digestion when milk or bread have been taken. It is seldom present 
after eating carbohydrates. It is found in traces only during the course of 
non-malignant disease of stomach. It is usually present in larger proportion 
in dilatation with stagnation of the gastric contents. If it is associated with 
retention and absence of HC1 it is strongly suggestive of carcinoma. 

Pepsin. — Marked diminution or absence indicates a corresponding dis- 
turbance of the glandular activity. It may exist, however, with a variety 
of lesions. 

Absorption and Motility. — The absorption activity of the stomach may be 
roughly indicated by Penzoldt's test : When 5 grammes of potassium iodide 
are taken in a gelatine capsule, iodine appears in the urine and saliva of the 
normal subjed within six to fifteen minutes, while with deficient absorptive 
capacity its appearance is much later. The iodine may be detected by 
applying a few drops of saliva or urine with one drop of strong nitric acid to 
starch paper, which, in the presence of iodine, turns blue or violet. 

Sahli's tesl of gastric efficiency consists in the use of a pill containing 
:i 9m all amounl of either iodoform or methylene blue, which is enveloped 

:| 3ir »aH bil of the rubber dam used by dentists, the neck of the little 
bag formed being tied off with the finest obtainable raw catgut. Such a 



SPUTUM 



35 



pill is given at the end of the ordinary noon meal and the urine passed at 
stated intervals during the afternoon and evening is either examined in 
regard to the first appearance of a greenish color if methylene blue was used, 
or is tested for the presence of iodoform in case this indicator was chosen. 
The latter substance has the practical advantage that it may be detected 
with equal certainty in the saliva. The appearance of either substance in 
the urine, or of iodoform in the saliva, indicates satisfactory gastric diges- 
tion and a negative result the reverse, the information obtained being, 
according to the author, a sufficient index as to the combined activity of the 
hydrochloric acid and the pepsin. 

The motility of the stomach is best determined by giving a test meal 
at night on an empty stomach, and examining the washings the next morning. 
Normally no traces of ingested food should remain. 

A chemical examination of the gastric contents simply shows us the chem- 
ical composition of the gastric secretion at the time the analysis was made, 
and is simply one factor in the diagnosis, prognosis, and therapeutics of 
digestive disturbances of whatever nature. 

SPUTUM 

GROSS CHARACTERISTICS 

Types of Sputum. — The following special types should be noted: 
Mucoid. — A good example of this is seen in chronic bronchitis. It is light 

in color, slightly translucent, viscid, tenacious, elastic, and very slightly 

aerated. 

Mucopurulent. — Seen in acute bronchitis. The admixture of pus with 
mucoid sputum renders it yellow, opaque, less tenacious and elastic. It is 
more completely aerated. 

Purulent. — In severe bronchitis, tuberculosis, and with rupture of lung 
abscess it may be pure pus. Purulent sputum has more pus than mucus 
and no viscid quality. 

Blood-Stained. — This is seen in acute bronchitis, pneumonia, tuberculosis, 
tumors of the lung and haemophilia. The blood exceeds the mucus. The 
viscidity is reduced, although the sputa remains coherent. 

Pure blood is expectorated in penumonia, phthisis, ruptured arteries, 
aneurysms, asphyxia, various septic conditions of infants, haemophilia, trauma, 
and some blood diseases. 

Rusty sputum is peculiar to lobar penumonia. It consists of gelatinous 
pellets of mucus slightly mixed with pus and uniformly tinged a rusty color. 
This type has been noticed after an attack of acute pulmonary oedema. 

Serous. — This is semifluid. Upon standing, it separates into two layers. 
Such mixtures are common in the terminal stages of bronchitis, in Bright's 
disease, tuberculosis, pneumonia, and endocarditis. 

Pure serum may be expectorated in acute cedema of the lungs, occurring 
in the initial stages of pneumonia or in nephritis with arterio-sclerosis. 

Fibrinous coagida are often mixed with the sputa in chronic bronchitis 
and pneumonia. Fibrinous casts of the bronchi may be expectorated in a 
type of chronic bronchitis. 



36 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



Gangrenous sputum is characteristic of putrefaction and necrosis of lung 
tissue Prune-juice expectoration, indicating a decomposition of blood, is 
common in pneumonia. Gangrene of the lung gives a most fetid discharge, 
which, upon standing, usually separates into three layers: the uppermost 
being frothy mucus and pus; the middle, serum; while the heavier, at the 
bottom, is solid portions of tissue. 

Nit m m ular sputum is the name given to purulent, coin-shaped sputa coming 
from old cavities with suppurating walls. Bile pigment may stain sputa 
in some of the severe forms of infectious disease and jaundice. Actinomyceces 
in colonics appear as small, white, partly calcified granules and resisting con- 
siderable pressure. Curschmann's spirals can usually be detected by the 
naked eye, as whitish, opaque, spiral, threads, 1 to 10 mm. in length. Masses 
of lung tissue arc small, grayish in color, and irregular in outline. Eazma- 
taidin is seen as dark brown particles resisting much pressure. 



MICROSCOPICAL EXAMINATIONS 

Mucus and fibrin appear in smear preparations as fine or coarse reticu- 
lated threads. Red blood-cells have their ordinary appearance. Epithelial 
cells from the mouth arc squamous; from the bronchi or nares columnar 
with or without cilia ; from the lung parenchyma they are rounded, large, and 
usually contain black pigment. In pulmonary congestion from endocarditis, 
the epithelium contains large brownish grains of blood pigment. Leucocytes 
are recognized by their multiple nuclei and clear bodies. 

Elastic fibres, occurring singly or in masses showing a distinct alveolar 
arrangement , are recognized as large, wavy, highly refractive threads lacking 
the double contour of vegetable fibre. They can be said to indicate destruc- 
tion of living tissue only when they appear in characteristic alveolar 
arrangement, and are most frequent in tuberculosis. They have also been 
found in bronchiectases, abscesses, and rarely in pneumonia. Charcot- 
Leyden crystals, elongated and diamond shaped, are found in chronic bron- 
chitis. Baematoidin, fatty acid, cholesterin, calcium carbonate, and triple 
phosphate crystals are also occasionally found. Curschmann's spirals, 
found in chronic bronchitis and asthma, frequently contain a number of 
Charcot-Leyden crystals within the meshes. 

Microorganisms. — Molds, aspergillus, leptothrix, and yeast fungi are some- 
times seen in sputum from phthisis cavities and abscess of the lung. The 
ray j annus i- observed in pulmonary actinomycosis. It appears as branching, 
interwoven threads, Inn ing swollen or club shaped ends, and can be easily 
demonstrated. Streptococci are frequently found in the mouth, and may 
have no pathological significance. In severe acute bronchitis they have been 
found in large numbers. With staphylococci, they are abundant in sputum 
from cavities. 

P«< """" I 1 plococcus lanceolatus) may often be found in the mouths 
of healthy individuals, but are especially abundant in the expectoration of 
pneumonia. The pneumobacillus of Friedlander is found in a few cases of 
pneumonia. It is encapsulated and resembles somewhat the pneumococcus 
except thai it is rod shaped, broader, longer, and has rounded ends. Both 
may be stained by Welch's method as follows, but the latter decolorizes by 



TRANSUDATES, PUNCTURE FLUIDS, CYST CONTENTS 



37 



Gram's method. Welch's Method. — The sputum is smeared, dried, and fixed 
on a glass slide by passing through a flame until the slide is as hot as the 
hand can bear. Then flood with glacial acetic acid, which is immediately 
drained off. Flood two or three times with aniline water gentian violet 
solution. Wash in a 2 per cent aqueous solution of sodium chloride, in 
which it may be mounted. It must not be washed with water. To prepare 
aniline water gentian violet, which must be used only when fresh, shake nine 
parts of distilled Avater with one of aniline oil, and filter through filter paper. 
To the filtrate add one tenth as much of saturated alcoholic solution of 
gentian violet. 

Bacillus of influenza is a minute straight rod, with rounded ends, often 
staining more deeply at the ends. This often gives it the appearance of 
diplococcus. It is found in immense numbers, singly or in clumps of one hun- 
dred or more and often within the bodies of leucocytes. They are best dem- 
onstrated by staining five minutes with a weak solution of carbol fuchsin. 

Tubercle bacillus can be found in the vast majority of cases of pulmonary 
tuberculosis. This bacillus grows in slender, straight, or slightly curved rods. 
The younger germs stain uniformly with carbol fuchsin, while the older present 
unstained points resembling vacuoles or spores, and sometimes present 
the appearance of a chain of cocci. They may occur singly, or two or more 
may lie side by side or end to end. Method of staining. — Fix the thinly 
spread sputum upon a glass slide by means of heat. Flood with carbol 
fuchsin for two minutes, gently heating. Wash thoroughly in water, 
and decolorize by flooding the specimen with acid alcohol solution for one 
minute. Wash in water, and counter-stain with aqueous methylene blue 
solution for about one minute. Wash in water, dry in air, and mount in 
balsam. The bacillus appears bright red, and the other parts of specimen 
are blue. 

Micrococcus tetragencs occurs in groups of four and are very frequently 
found in tuberculosis, associated with the tubercle bacilli. When found with 
the latter they are said by Hoch to be an indication of cavity formation. 
They stain readily with all of the aniline dyes, particularly methylene blue. 

The smegma bacillus stains with almost as great a tenacity as the tubercle 
bacillus, and to distinguish it from the tubercle bacillus the specimen must 
be decolorized in alcohol for about eight to twelve hours, after which time 
the smegma bacillus is decolorized. 

TRANSUDATES, PUNCTURE FLUIDS, CYST CONTENTS 

Aids to Differentiation. — Collections of serous fluid in body cavities or 
tissue spaces as the result of mechanical disturbance of the circulation, 
changes in the blood or in the walls of the vessels, unaccompanied by inflam- 
matory phenomena, are true transudates. 

The careful chemical and microscopical examination of the fluid is an aid 
to differentiation between an exudate and a transudate. The specific gravity 
in transudates is usually lower than 1.015, while in exudates it is higher than 
1.018. The albumin content in transudates is less than in exudates. In 
the former it averages between 1 per cent and 2.5 per cent and in the latter 
4 per cent to 6 per cent. As exudates are inflammatory in origin, we expect 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



,,, find the products of inflammation, pus, epithelial cells, microorganisms, 
etc., while in transudates these elements are not usually present and occur 
only after long standing and introduction of infectious elements from without. 
Cyst contents may show the echinococcus hooklets, which are diagnostic. 

EXUDATES 

Exudates are inflammatory in origin, and their examination can aid as 
to the cause of inflammation. They may be serous, bloody (hemorrhagic), 
fibrinous (serofibrinous), purulent (seropurulent), or chylous. Chyloid ex- 
udates differ from the chylous in that they contain much less free fat. 
The turbidity is due rather to cellular debris and lecithin. They may 
coagulate in the cavity or after aspiration. Microscopical examination is 
most important for the detection of isolated cells, or larger particles of a 
tumor, or of tubercle bacilli, gonococci, or other pyogenic microorganisms. 

Tuberculous exudates are usually serous or hemorrhagic, the latter form 
indicating more severe inflammation. A hemorrhagic pleuritic exudate is 
usually tuberculous, and pleuritic exudates are more usually bloody than 
those of the peritoneum. Bacilli are present in tuberculous exudates in very 
small numbers, but in the necrotic foci they are more abundant. Rarely 
they may be found by staining the sediment. The best test, however, is 
inoculation into the peritoneal cavity of a guinea-pig. 

Carcinoma or endothelioma of serous membranes is frequently accompanied 
by an exudate, which is usually serous, but often bloody. Isolated cells, or 
small masses of tumor, may be found in the sediment; but the cells must 
show the mitotic changes under the microscope to give a positive diagnosis. 
The diagnosis can frequently be made upon this basis of the presence of 
atypical epithelial cells alone. 

Joint fluids usually contain mucus and are viscid. The exudate of 
traumatic or rheumatic synovitis is usually clear and sterile; while in tuber- 
culous synovitis the fluid may be bloody or seropurulent, and tubercle bacilli 
may be demonstrated. In gonorrhceal synovitis fluid is serous or seropurulent 
and the gonococcus may often be demonstrated. 

Discharges. — The gonococcus occurs principally in genitourinary dis- 
charges, bu1 may be found in gonorrhceal infections of the rectum, mouth, 
eyes, serous cavities, and also in the blood. The usual location, however, 
is in the genitourinary tract, where it grows on surfaces lined by columnar 
epithelium. In the male, the gonorrhceal germ is found in acute and chronic 
urethral discharges. In gonorrhceal cystitis it is found in the threads, so- 
called "gonorrhceal shreds." In the female it is most abundant in and 
often limited to the urethral pus. Next in frequency it is found in the dis- 
charges from the cervix uteri. In the vaginal discharge other diplococci are 
often present, which makes differential diagnosis difficult. Hence it is always 
better to take the pus from the urethra or cervix. In female children the 
gonococcus is often found in the vaginal discharge, but seldom in the ure- 
thra. Children do not usually have gonorrhceal cystitis. 

In looking for the gonococcus, we must note the following characters: It 
mus1 ! " :I biseuil shaped diplococcus. It must be found within bodies of 
pus cells. It must be decolorized by Gram's method. 



EXUDATES AND DISCHARGES 



39 



Gram's method of staining gonococci : 

The pus is smeared and fixed on a glass slide. Flood the specimen for 
60 seconds with aniline water gentian violet, and blot off. Flood with 
Gram's iodine solution for one minute, and blot off. Decolorize in alcohol, 
97 per cent, for two to four minutes. Counter-stain in saturated aqueous 
solution of Bismarck brown for one to three minutes. The biscuit shaped 
gonococcus is then seen stained brown within the cell bodies of the 
leucocytes. 

The anthrax bacillus is present in large numbers in the exudate of malig- 
nant pustules. An aqueous solution of methylene blue (Loeffler's solution) 
stains it very well. 

Pharyngeal exudate is frequently examined for evidence of diphtheria 
and other diseases of this region. A complete investigation of this exudate 
demands three procedures: 1. Morphological examination of the exudate. 
2. Biological examination. 3. Test by inoculation. 

1. Morphologically the Klebs-Loeffier bacillus, or the Bacillus diph- 
therias, is usually distinct. When only a very few bacilli are found and 
many cocci, we must resort to the biological test. 

2. A smear from the throat is gently rubbed over the surface of a blood 
serum culture medium, and the latter kept in a thermostat for from twelve 
to twenty-four hours. Under these conditions the Klebs-Loeffler bacillus 
grows rapidly, outstripping other microorganisms found in the mouth and 
throat. After twenty-four hours the colony has a sharply outlined, slightly 
elevated, granular, dry, creamy yellow or grayish growth. Some of this 
growth is then to be transferred to a slide by the aid of a sterilized plati- 
num wire, mixed thoroughly with a little water, spread into a thin film, 
and then dried, fixed, and stained. The preparation should be examined 
under the microscope with a yV oil immersion lens. The methylene blue 
solution: Saturated alcoholic solution of methylene blue, 30 parts; Aqueous 
solution of potassium hydrate (1 in 10,000), 100 parts. Stain for about one 
minute. 

N. B. — Before a morphological diagnosis can positively be made of B. 
Diphtheria?, it is essential that certain conditions be fulfilled, viz.: 

1. Smear is from naso-pharyngeal or laryngeal exudate. 

2. Culture must be growth not older than 16 hours at 37° C. 

3. Growth has been made in Loeffler's blood serum. 

4. Morphological characteristics must be typical. 

3. In a case of mild pharyngitis, even with the above described tests, 
we cannot always diagnosticate diphtheria without inoculation. Method 
of inoculation: One half a cubic centimetre of a forty-eight hours' broth 
culture of the bacillus to be tested is injected subcutaneously into a guinea 
pig. Cultures of ordinary virulence will cause the death of the animal 
in thirty-six hours. If of slight virulence, the culture may require from 
three to four days to cause death, or it may fail to kill. Non-virulent 
cultures produce no distinct effect upon the animal. 



Ill 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



STAINS 

Carbol Fuchsin Solution: 

Fuchsin (basic, not acid) , 1.8 parts ; 

Carbolic acid, 5.0 parts; 

Alcohol, 10.0 parts; 

Distilled water, 100 . parts. 

Acid Alcohol Solution: 

Absolute alcohol, 290.0 parts; 

Concentrated hydrochloric acid, 10.0 parts. 

Methylene Blue Solution: 

Methylene blue, 10 parts ; 

Sodium chloride, 0.6 parts; 

Distilled water, 100 .0 parts. 



BREAST MILK 1 

In mother's milk we may wish to estimate the amount of fat and pro- 
teida and to determine the specific gravity. By means of any small hy- 
drometer, graduated from 1.010 to 1.040, we may determine the specific 
gravity of milk that has been expressed by hand or by means of the breast 
pump. The average is 1.031. 

To approximately determine the percentage of fat, a small calibre test 
tube, graduated from 1 to 100, is filled to the 100 mark with milk pumped 
from the breast. An indefinite amount of ether is added, and the contents 
arc thoroughly shaken. On standing for half a day the liquid separates 
into two layers, ether and fat, and milk minus fat. If, for example, the 
point of demarcation between the two layers is at 97, there is 3 per cent 
of fat. 

To estimate the proteids, decant the ether and fat from the tube and 
precipitate the casein contained in the skim milk by the addition of acetic 
acid or rennet. The curd formed is then collected on a filter (the weight 
of the filter being known), and the salts, etc., are washed out with water. 
The filter and curd arc dried in an oven and weighed together. Deduct 
the weighl of the filter from the total weight, and the remainder will give 
I he weighl of I he curd. For example, if in a test tube graduated in grammes 
the weighl of the curd is found to be 2.0 grammes, the percentage of pro- 
teid is 2 approximately, if the quantity examined has been 100 grammes. 

CULTURES 

m time to time it is of advantage to be better acquainted with 
the microorganism than is possible from microscopical examination of pus 
or fluids as they are taken from different parts of the body. The study 
oi bacteriology has demonstrated that a given microorganism seems to 
thrive better in one medium than in another. This knowledge enables 
us to obtain an early aiid abundant growth. 

The bacteria which it is most often desirable to study by growth in 
culture ned,:, arc- The Klebs-Loeffler bacillus of diphtheria, the colon 



' Holt has devised an inexpensive milk tester. 



CULTURES 



41 



bacillus, the streptococcus, the staphylococcus, the Bacillus pyocyaneus, 
the pneumococcus, the gonococcus. 

Klebs-Loeffler Bacillus. — The Klebs-Loeffler bacillus grows best and 
most rapidly on blood serum. Its colonies are large, round, elongated, 
grayish, white, or yellowish, with the centre more opaque than the slightly 
irregular periphery. The surface of the colony is at first moist, but after 
a day or two becomes rather dry in appearance. 

Rapid Bacteriological Diagnosis of Diphtheria. — Loeffler sugar blood 
serum. A sterile cotton swab is drawn over the exudate in the pharynx 
or on the tonsil, and smeared over the surface of a blood serum culture 
medium. After the test tube is inoculated, it is placed in an incubator, 
which has previously been heated to between 37° and 38° C. (98.6° and 
99° F.). A small water oven, such as is in use in laboratories, just large 
enough for the test tube, is very good. It can first be heated to 37° or 
38° C. with a Bunsen burner and kept at that temperature by means of an 
ordinary small kerosene lamp. The tube is left in the oven for two and a 
half to three hours, and then the growth is removed by means of a platinum 
wire loop. The smear is made as in staining for examination under the 
microscope. 

Colon Bacillus. — The colon bacillus seems to grow most characteristically 
upon gelatin, and grows both with and without oxygen, on the surface 
and within the gelatin. On the surface the colonies appear as small, dry, 
irregular, flat, blue-white points that are commonly somewhat serrated 
at the margin. They are a trifle more dense at the centre than at the 
periphery, and are often marked at or near the middle by an oval or round 
nucleuslike mass. Examined by a low power lens, they are at first seen 
in the depths of the gelatin as finely granular, very pale greenish yellow, 
round, oval, and lozengelike colonies. Later they appear denser, darker, 
and more markedly granular. 

Streptococcus. — The streptococcus appears on gelatin plates in from 
forty-eight to seventy-two hours as very small, flat, round, bluish-white 
and opalescent points. In gelatin stab cultures it grows along the entire 
needle track as a finely granular line, the granules representing minute 
colonies of the organism. 

Staphylococcus. — The staphylococcus aureus, grown on agar-agar, 
usually appears to the naked eye as round, moist, glistening, yellow or 
orange colored colonies. When situated in the depths of the medium, 
they are commonly seen to be lozenge-shaped or whetstone-shaped, often 
as irregular stars with blue points, and again as dense, irregularly lobulated 
masses. After thirty-six to forty-eight hours, a pure stab culture in gelatin 
produces liquefaction along the line of the needle track. As the culture 
becomes older, liquefaction increases until all the gelatin in the tube be- 
comes liquid. 

Bacillus pyocyaneus, the bacillus of green pus, blue pus, or blue-green 
pus, as it is commonly called, when grown on gelatin plates, develops a 
round, not sharply defined mass, which at first usually presents a peripheral 
fringe of delicate filaments. As growth progresses, liquefaction occurs, 
and as the latter advances, the central mass of the colony sinks into the 
liquefied depression, while laterally the colony extends. 



42 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



A stab culture' in gelatin is accompanied with liquefaction, and diffusion 
of a bright green color takes place throughout the unliquefied gelatin. All 
the gelatin finally becomes liquid, and the green color is confined to the 
superficial layer in contact with the air. 

Gonococcus.— The gonococcus grows well on blood serum mixed with 
agar. The gonorrhceal pus should be mixed with uncoagulated serum and 
the mixture added to one or two parts of melted agar at about 40° to 50° C. 
This mixture is allowed to solidify in an oblique position in the tube. The 
late method is the one commonly employed. Superficial colonies are 
.Ascribed as having a compad centre with a very delicate, transparent, 
finely granular zone with projections like peninsulas on a map. Deeper 
colonies are solid, clumpy, with a sharp, regular contour. 

Pneumococcus. — The pneumococcus seems to grow best at rather 
higher temperatures than that of the room (at about 78° to 79° F.) and 

upon a strongly alkaline medium 
or blood serum. The colonies ap- 
pear small, distinct, round, and 
transparent, resembling dew drops. 

BLOOD 

Examination. — For the exami- 
nation of the blood, the apparatus 
necessary includes : 

A hsemoglobinometer (Gowers's 
or Fleischl). 

A Thoma-Zeiss counting ap- 
paratus. 

Microscope slides, cover glasses, 

etc. 

Gowers's Method. — To estimate 
the relative amount of haemoglobin 
in a given case, the tip of the finger or lobe of the ear is punctured after 
having been thoroughly cleansed with alcohol or ether. The blood is drawn 
by -union into the pipette up to the 20 cm. mark. Any trace of blood that 
may adhere to the outer surface of the pipette is carefully wiped off and 
the contents are at once mixed with a few drops of distilled water previ- 
ously placed in the graduated tube so as to guard against the blood coag- 
ulating on its walls. Clean out the pipette as carefully as possible, so 
thai every particle of blood is washed into the tube. Hold the two tubes 
side by side directly against the light, and add distilled water, drop by drop, 
unt il t he shade of color is the same in each tube. The division on the scale 
thus reached will express the relative percentage of haemoglobin. The 
quist haemoglobin scale greatly simplifies the estimation of haemoglobin. 
A drop of blood is allowed to soak into a prepared blotting paper, which 
sold as leaves of a small book. While it is still moist, compare its color 
with a color M ale representing the different percentages of haemoglobin. 

Counting the Cells.— Counting of the blood cells is a trying and tedious 
procedure, but is of great value in many cases. The apparatus consists 
of a slide (a), upon which is arranged a chamber (b) the floor of which is 




Fig. 9. — Hsemoglobinometer. 



BLOOD EXAMINATION 



43 



B- 



marked most accurately into little squares (c). The chamber is exactly 
. 1 mm. in depth, and each of the sixteen small squares contains 
c.mm. A capillary pipette with a bulb on the up- 
per third has graduations marked . 1 mg. to 1.0, 
while above the bulb it is marked 101. 

The tip of the finger or lobe of the ear is 
punctured after thoroughly cleansing the parts and 
apparatus. The finger should be cleaned with soap 
and water, then with alcohol and ether. The exud- 
ing blood is drawn into the capillary tube to the 
mark . 5 or 1 . 0, according to the degree of dilution 
desired, care being taken to exert very slight press- 
ure upon the finger. Then, after wiping the tip 
of the pipette, sufficient 6 per cent salt solution is 
drawn into the pipette to fill the bulb and reach 
the 101 mark. Mix thoroughly by shaking. Blow 
out the contents of the capillary tube below the 
bulb, as they are probably only salt solution, and 
then blow a drop of the mixture upon the counting 
chamber, immediately covering it with a cover 
glass (/), bubbles of air being carefully expelled. 
After allowing the corpuscles three to five minutes 
to settle, they are then counted, going over at least 
one whole field (200 squares) or, if special accuracy 
is desired, two whole fields (400 squares) when 
counting the red cells and 400 squares when count- 
ing the leucocytes. 

In order to obtain the number of red corpuscles 
contained in one c.mm. of blood, the total number 
noted is divided by the number of small squares 
counted, the result being the average number in FlG - 
one small square. Example: Suppose 1,200 red 
corpuscles were counted in 400 small squares, the 

average number contained in one, that is t^Vo c.mm., of diluted blood 
would be 3, — corresponding to 12,000 corpuscles for each cubic millimetre. 
If the blood is diluted 200 times, multiplying by 200 would give 2,400,000 
in one c.mm. of the undiluted blood. Drs. Einhorn and Laporte have 



A 



10. — Thoma-Zeiss 
Pipettes. 




Fig. 11. — Counting Slide (plan). 



44 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



invented a rapid blood counting method by means of a blood counting 
diaphragm manufactured by Eimer & Amend, of New York City. 

In counting leucocytes, it is better to have a special pipette, allowing 
a dilution of from 1 to 10 or 1 to 20. For diluting, a 0.3 or 0.5 per cent 
solution of acetic acid is used, which destroys the red blood cells. The 
same method of mixing, preparing the drop on the slide, and counting 
one as for red cells. Red cells are normally 5,000,000 per c.mm.; 
leucocytes, from 5,000 to 8,000. 

Significance of Hyperleucocytosis 

Physiological. — In children, Hayem says, 18,000 are found in the first 
eighty hours of life, 9,000 during the first month, and 8,000 up to the fourth 
They arc also found during digestion, immediately after a cold 
bath, and during the last five months of pregnancy. 

Pathological. — " Leucamiia " is not usually classed under " hyperleucocy- 
tosis." The latter term is generally employed to indicate an increase in 
the multinuclears in transitory conditions. Leucaemia is a permanent 
condition. In leucaemia the proportion of white cells may be 1 to 10 or 1 
in "), or 1 to 1 of the red cells, while normally it is about 1 to 8,000 or 1 to 
10,000. 

In acute inflammatory diseases, in general the degree of hyperleucocy- 
tosis is directly proportionate to the degree of local reaction. For example, 
in typhoid fever the local reaction is slight, but if there is a complicating 
pneumonia or pleurisy in which the local reaction is great, a correspond- 
ingly marked hyperleucocytosis will be found. 

In pneumonia the degree of hyperleucocytosis may serve as a direct 
index of the amount of lung tissue involved, disappearing during the crisis 
or even a few hours before it sets in. In phthisis it occurs apparently only 
when the disease has led to the formation of cavities (secondary or mixed 
infection). In t lie cachexia of malignant disease it is often of great intensity, 
and n i- said to be of value in the differential diagnosis between malignant 
and benign disease of the stomach. 

PREPARATION OF BLOOD SLIDES 

Preparation of blood slides, for the examination of the blood cells and for 
Plasmodium Malaria. After scrubbing the finger tip or lobe of the ear 
with soap and water, and then with alcohol and ether (it often suffices to 
rub well with ether alone), a blood drop is drawn with a sterile lance or 
needle. Then pass the end of a slide, cleaned with ether and alcohol, through 
the drop and smear over the properly cleaned slide. It must be most care- 
fully done, and no grease must be on the slide. 

It is first stained with Jenner's alcoholic solution of eosin, or methy- 
lene blue 5 to 10 minutes, the slide being examined from time to time to 
see if the depth of stain is sufficient. When sufficiently stained, it is 
washed with water, and dried, and is then ready for examination under 
the microscope. A 1-12 oil immersion lens should always be used when 
possible. . 



DISEASES REQUIRING BLOOD EXAMINATION 



45 



DISEASES REQUIRING BLOOD EXAMINATION 

Chlorosis. — In chlorosis we observe: Diminution of hsemoglobin, 60 per 
cent to 20 per cent; low hsemoglobin index = ratio between the percentage 
of hsemoglobin and the number of red cells; the number of red cells may 
be nearly normal, rarely less than 2,000,000; the red cells show a large 

Cover glass. 



^B 




Ruled disk. Moat. 
Fig. 12. — Blood Counting Slide (elevation). 



unstained central area, indicating a loss of hsemoglobin ; in severe cases the 
shape and size of the red cells may be changed, and nucleated red blood cells, 
called normoblasts, are often seen; the leucocytes are usually but little 
affected. There may be a slight increase in all varieties. 

Secondary Anaemia. — The blood is impoverished in all cases attended 
with malnutrition, toxaemia, or hsemorrhage. To make a diagnosis of this 
form of ansernia, we should first recognize the presence of a primary disease, 
such as carcinoma, ulcer of the stomach, nephritis, rhachitis, malaria, syph- 
ilis, etc., and then note in the blood examination: The hsemoglobin may be 
as low as 15 per cent; the red cells as few as 1,000,000; the hsemoglobin index 
not so low as in chlorosis; a moderate number of multinuclear leucocytes, 
the presence of which often characterizes the blood of secondary ansernia. 

Pernicious Anaemia is a disease of the blood-producing organs tending 
to a fatal issue. On examination we find: the haemoglobin usually below 
25 per cent; the red cells always fewer than 2,000,000, 
and frequently below 1,000,000; the hsemoglobin index 
usually increased, as there is an increase of hsemoglobin 
in the remaining red cells; characteristic changes in the 
size and shape of the red cells, megalocytes; mis- 
shapen and deformed red cells of all sizes — poikilocytes ; 
the hsemoglobin in many cells changed so as to make it 
stain brownish with eosin — polychromatophilia ; nucle- 
ated red cells of large size, called megaloblasts, their 
presence in large numbers being pathognomonic of the 
disease; microblasts, staining brownish with eosin; red 
cells not collecting in rouleaux; the plasma of the blood 
perhaps staining with eosin, indicative of hsemoglobin solution in the plasma 
— hsemoglobinsemia ; the leucocytes usually diminished, those remaining 
being principally of the uninuclear variety. 

Splenic Anaemia is classed as a disease of the spleen. It is usual to 
find a reduced number of red blood cells, the hsemoglobin is relatively low, 
and the leucocytes are reduced in number. The changes are associated 
with enlargement of the spleen. 




Fig. 13. — Blood 
Counting Dia- 
phragm. Actual 
Size (Drs. Ein- 
horn and Laporte) . 



Hi 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



Hodgkin's Disease has those changes in the blood of the microcytic 
form of pernicious anaemia. 

Secondary Pernicious Anaemia. — The severe grades of secondary anaemia 
most frequently result from malaria, syphilis, carcinoma, nephritis, and 
tuberculosis. On examination we find: 

The red cells may show an excess of haemoglobin (megalocytic type), 
unless, as is usual in the very acute cases, they are normal or reduced in 
size and show a deficiency of haemoglobin (microcytic type); megaloblasts 
are usually absent; a persistent multinuclear leucocytosis usually serves 
to distinguish the blood of secondary from that of primary pernicious 
ana'inia. 

Leucaemia.— A disease of the blood and blood-producing organs charac- 
terized by progressive anaemia, increase in the white cells of the blood, 




Fig. 14. — Counting Blood Cells. 



and certain changes in (he viscera. In many respects it resembles a tumor 
formation in a fluid tissue. 

Myelogenous Leucaemia.— The chief feature of the blood in this form 
is t he presence of a large number of myelocytes and multinuclear leucocytes. 

There are three varieties of myelocytes: 1. Ehrlich's myelocyte, of the 
3ame 3ize multinuclear leucocytes, with a single pale central nucleus 

and neutrophil granules. This form is seen in secondary anaemias, but 
is abundant in myelogenous leucaemia. 2. Cornil's myelocyte, a very 
' ar 6 e ullM ;l single pale eccentric nucleus and neutrophile granules. 
This cell is seen almost exclusively in this disease. 3. The eosinophile 
myelocyte, a uninuclear leucocyte with unusually large and darkly staining 
eosinophile granules. This ceil has been observed only in this disease. 



DISEASES REQUIRING BLOOD EXAMINATION 



47 



Mast cells are seen in considerable numbers only in chronic myelogenous 
leucaemia. 

Lymphatic Leucaemia. — In this form the increase is of the small and 
medium sized lymphocytes, while multinuclear leucocytes are scanty and 
myelocytes and mast cells are absent. 

Malarial Parasites. — The Plasmodium of malaria has its life process in 
the red blood cell, and it discharges the embryo into the plasma, this dis- 
charge being simultaneous with the chill. There are three forms: 

1. The tertian, which gives a chill every forty-eight hours. 2. The 
quartan, every seventy-two hours. These two forms are very much alike, 
and can readily be demonstrated under the microscope. 3. The cestivo- 
autumnal type usually gives paroxysms every seven days and is undisturbed 
by quinine, except the chill, which is arrested. All these forms can be 
studied when they are alive in fresh blood or in stained specimens. 

To study a fresh specimen of blood, the fingers, slide, and needle should 
be scrupulously clean and aseptic. A small drop of blood is placed upon 
the slide and a cover glass placed over it, when it is ready for study. The 
parasite is best studied in diagrams, where the different forms, indicating 
its degree of development, can be compared. Probably the best time to 
take a specimen is from twelve to eighteen hours after a chill, and the 
most characteristic feature is the granules of dark brown, nearly black 
pigment. 

Widal Reaction. — This reaction depends upon the observation of Pfeiffer, 
that the action of the blood serum of a typhoid fever patient upon a minute 
quantity of a pure typhoid culture causes a loss of motility of the individual 
germs and also their so-called "clumping," an agglutination of the bacilli. 
It is found distinctly upon the fourth to the seventh day in 70 per cent of 
cases; upon the eighth to the tenth day in 80 per cent of cases; upon the 
third to the fourth week in 90 per cent of cases. It is absent throughout 
the disease in from 5 to 10 per cent of the cases. We also find all degrees 
of reaction. Sometimes there is an instantaneous loss of motility, some- 
times in fifteen minutes, and sometimes there is only a partial loss of 
motion. Many other diseases give this partial reaction, only in low dilutions. 

If the dilution of the blood is 1-10, and the reaction is present, the 
diagnosis is particularly certain; if 1-20, the diagnosis is absolutely certain. 
Absence of the reaction is not an assurance that the disease is not typhoid, 
but such cases are usually mild. The reaction is often slight or absent 
in cases ending fatally. In cases in which the Widal test is negative, 
infection with bacilli of the paratyphoid group should be suspected. 

Procedure: A drop of blood from the patient is dried upon a slide just 
as it exudes from the finger punctured after due antiseptic precautions. 
Then dilute 1-10 times or 1-20 times with sterile water. Place on a cover 
glass by means of a platinum needle a drop of a twenty-four hour bouillon 
culture of the typhoid bacillus, or a pigment of an agar culture growth. 
Mix it with the diluted blood serum and invert it over the hollow of a slide 
made for the " hanging drop." In order to prevent all possibility of spread- 
ing any infection and getting a pure culture, the platinum needle should be 
held in the flame of a Bunsen burner or alcohol lamp both before and after 
each use. It is also a good plan to make a narrow ring of vaseline around 



is 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



thi hollow in the slide for the hanging drop and to place the cover glass 
upon it to prevent slipping. The specimen is now ready for study. The 
Widal reaction seldom appears before the second week of the fever, and 
may be delayed even until convalescence. In a small number of cases it 
may never be present (paratyphoid?). In others it may be intermittent. 
\s it seldom appears before the beginning of the second week, the test is of 
little value up to this time. As it often appears late in the disease, and 
as it may be present only intermittently, typhoid fever cannot be ex- 
cluded by a single, or even by repeated negative tests. Repeated negative 
however, are very strong evidence against the existence of typhoid. 
A positive reaction, if the patient has not previously had typhoid, is almost 
certain proof of typhoid. A negative reaction, followed by a positive re- 
action in a dilution of 1-50, is absolute proof of typhoid. The Widal 
reaction can also be determined by using serum instead of blood. 

The reaction has been found by Scholtz as long as fifteen years after 
typhoid, and by Kasel and Mann as long as twenty-one years after recovery, 
[f this were true, it would explain our practical immunity from a second 
attack. Cases of enteric fever presenting all clinical evidence of typhoid 
fever, bul without the Widal reaction, are said to be due to a paratyphoid 
bacillus, and are termed "paratyphoid," for which a special test has been 
devised. 

A macroscopic Widal reaction is obtained by taking up serum in a grad- 
uated pipette and diluting it to the desired degree (usually 1 in 40) with a 
live or dead (formalized) typhoid culture. The mixture is placed in a 
small test tube and allowed to stand. A time limit of three hours is set. 
A positive reaction is obtained when the bacilli are agglutinated and falling 
to bottom of tube leave a clear supernatant fluid. 

Filaria. — Occasionally it is desired to examine the blood for the parasite 
causing elephantiasis, the Filaria sanguinia hominis. A peculiarity of the 
-lie is t hal it can be found in the blood only when the patient is at rest. 
So for one occupied during the day the blood specimen to be examined is 
taken at night, and vice versa. It can be found at any time. 

Iodophilia.— This is a blood test first described by Dr. Theodore Dunham, 
of New York, who says: "I have ventured to coin this word to designate 
a reaction which occurs in the blood under certain pathological conditions. 
I bring this subject before you because this reaction has been a definite 
help to me in diagnosis, and I feel that it deserves a more extended use than 
it has yet received. The cases in which it gives aid are those of doubtful 
suppuration and doubtful pneumonia. We are not infrequently confronted 
with cases of appendicitis where an additional aid to the early recognition 
of pus would be of the greatest value; and there are other cases of deep- 
seated trouble with doubtful physical signs where an additional means of 
throwing light on the presence or absence of pus would be a great help. 

imonia is often difficult of recognition during the first few days after 
the onset. An additional aid in diagnosing it during this stage would be 
of real value. 

' l et me say a word about the technique of the reaction and then speak 
of its clinical bearings. The technique is very simple. It consists in the 
staining and examination of a spontaneously dried blood smear. The 



DISEASES REQUIRING BLOOD EXAMINATION 



49 



smear need not be stained at once, but will be good for use several weeks 
at least after making. It is thus possible to make the smear at the bedside 
and send it to the laboratory for staining and examination. Only one 
solution is required, and this is made up as follows: Three parts of potassium 
iodide are dissolved in one hundred parts of water. In this is dissolved one 
part of iodine. The resulting solution is thickened to a syrupy consistence 
by the addition of lumps of gum arabic and occasional shaking until they 
are dissolved. The blood smear is mounted in a drop of this syrup, and 
a bit of filter paper placed at an edge of the cover glass to absorb the excess 
of fluid. The specimen is then ready for examination by an oil immersion 
lens. When blood is treated in this way the lymphocytes and the eosino- 
philes are not affected by the stain. 

"It is apparently always present in progressive suppurations and in 
progressive pneumonias. It may also occur in a few other diseases, but 
they are fortunately easy of recognition in other ways and not to be con- 
founded with abscess or pneumonia. The intensity of the reaction is said 
by other observers to be closely related to the intensity of the process, 
and I have found this to be true in the cases I have examined. Small 
abscesses will, however, if the process be active, give a distinct reaction. 
In cases of so-called tuberculous abscess the reaction is absent. Abscesses 
caused by the germs of acute suppuration, but which are well walled off 
and have assumed an indolent CQurse, rarely give the reaction. If, however, 
the process lights up again, the iodine reaction is said to return. Gold- 
berger and Weiss, from an examination of a considerable number of other 
diseases as well as of abscess, reach the conclusion that a distinct intracellular 
iodine reaction, even if made out in only a few leucocytes, warrants the 
conclusion that there is present a progressive suppurative process. In 
reaching this conclusion, of course the few other lesions which give rise 
to iodophilia must be excluded. 

" Let me now speak of the relation of iodophilia to pneumonia. Other 
observers say that the iodine reaction occurs constantly in pneumonia. 
I have found this to be true in the cases which I have examined. The 
reaction would not be of great value in pneumonia if it were present only 
when consolidation was so far advanced as to give a typical picture of the 
disease, for then the usual diagnostic signs are sufficient. But in two cases 
where I have examined the blood at an early stage, before physical or other 
signs were specially suggestive of pneumonia, I found a well marked iodo- 
philia. This early appearance of iodophilia in pneumonia I have not seen 
referred to by others, and know of it only from the two instances where I 
looked for it. If it proves to be uniformly present soon after the onset, 
iodophilia will be one of the earliest diagnostic signs of pneumonia. 

"As I have already said, certain diseases must be eliminated from the 
diagnosis before one concludes that iodophilia implies the presence of pus 
or pneumonia. Hofbauer, at Neusser's clinic in Vienna, found that iodo- 
philia occurred in certain grave blood diseases. In eighteen cases of chlorosis 
he failed to find it. In eighteen cases of secondary anaemia he found it 
in two, but one of these was complicated by pyothorax and the other by 
gonorrhceal annexa, and its presence was probably due to these complica- 
tions. But in really grave anaemia, as that associated with cancer of the 
5 



M LABORATORY AIDS TO CLINICAL DIAGNOSIS 

stomach severe chronic intoxications, etc., where the blood picture ap- 
proached that of pernicious anaemia, he regularly found a greater or less 
number of Lodophile leucocytes in the seven such cases he examined. In 
advanced pernicious ansemia and in leucaemia he also found it. I found it 
very marked in I he one case of leucaemia which I have examined in this way. 

'•• \< iodophilia is a natural accompaniment of these diseases, in them 
itfi presence throws no light on the existence of pus or pneumonia. During 
an examination with the iodine test these grave blood diseases would surely 




Fig. 15. — Making a Blood Smear on a Slide. 

be recognized. With their elimination, the finding of iodophilia points to 
acute suppuration or to pneumonia." 



TISSUE SPECIMENS 

Preparation for Microscopical Examination. — The specimen is cut into a 
cube of aboul oneandahalf centimetres in each dimension. It is hardened 
by running ii through the following solutions the specified length of time: 

4 per cent formalin, 24 hours. 

80 " " alcohol, 24 

90 " " " 24 

100 " " " 24 

100 " " » and ether, each 24 

3 " " celloidin, 24 

6 " " " 24 



(better one week) . 



CALCULI 



51 



Block and leave in 70 per cent alcohol for twenty-four hours. Cut 
sections on a microtome. Stain in haematoxylin for from three to five 
minutes (Delafield's preparation diluted three times); H2O + a few drops 
of ammonia, for a few seconds; H2O for half an hour; alcoholic solution 
of eosin, for 1 to 2 minutes; alcohol, 90 per cent, for a few seconds; alcohol, 
100 per cent, for a few seconds. Then place in oil of origanum, bergamot, 
or cloves until they are ready to mount in Canada balsam. 



ANALYSIS OF DRINKING WATER 

Chemical Examination. Tests. — Test for total solids; hardness; 
chlorine; free and albuminoid ammonia; nitrates; nitrites. 

The first three tests are a measure of the mineral constituents, while 
the last three show the organic contents of the water. If the history of 
the water is known, an excess of chlorine may point to sewage contami- 
nation. The free and albuminoid ammonia indicate animal and plant 
pollution. A large amount of nitrates usually shows that the water has 
been purified by oxidation. Nitrites should never be present to any 
amount in surface water. 

Bacteriological Examination. — We wish to know if the water has been 
polluted by sewage; if there are bacteria, whence they are probably de- 
rived. The finding of the colon bacillus accompanied by the germs of 
putrefaction, if at the same time the chemical analysis shows an excess 
of nitrites or albuminoid ammonia, is sufficient reason to pronounce 
water unfit for drinking. The test for the colon bacillus and typhoid 
bacillus, with accompanying putrefactive bacteria, is accomplished by 
means of cultures and gross and microscopical examination. 



CALCULI 

Renal Calculi may be composed of uric acid, calcium salts, or phosphates. 
The nucleus is formed by a deposit from an excess of the crystalline particles 
of the urine. These particles become adherent through a bit of mucus or 
clot of blood, and fresh deposits are gradually added to the nucleus. The 
shape is usually irregular, conforming to the shape of the pelvis of the kidney 
and its branching calices. 

Ureteral Calculi. — A stone from the kidney may descend into the ureter, 
and become lodged there. 

Vesical Calculi have for nuclei uric acid crystals, a mass of inspissated 
mucus, or some small foreign body. They may be primarily formed in the 
kidney. We usually find them to be composed of urates and uric acid, 
phosphatic salts, or oxalate of lime. Rarely one is found composed of 
cystin. The framework which holds the crystals together is albuminous, 
and thus it is essential to stone formation, to have an abnormal urine, 
such as one containing inflammatory products, mucus, or blood, and one 
at the same time rich in salts. A stone may gradually increase in size so 
that in time it is possible for one to fill the bladder. Occasionally elonga- 



52 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



tions extending into a ureter, the urethra, or a vesical pouch may form. 
( >ne may begin in the prostatic sinus, and enlarge backward into the bladder 
or forward into the urethra. Vesical calculi may be multiple. 

Urethral Calculi are rare, but it is possible to have a vesical or renal 
calculus lodge in the urethra behind a stricture. 

Prostatic Calculi with nuclei of organic matter (prostatic secretion), 
upon which salts of lime may be deposited, may be found in the prostatic 
ducts or scattered throughout the gland. 

Calculi with hair attached point to the presence of a dermoid cyst. 

Gall Stones usually form in the gall bladder, but occasionally in the ducts 
or biliary passages of the liver. Cholesterin and bile pigments form the 
basis, but there must be some obstruction of the passages and inflammation 
of the mucous membrane to allow of their precipitation from stagnant 
bile. There may be a single stone or many, and the size varies from that 
of a small gravel to two to three inches in diameter. 

Pancreatic Calculus. — Rarely a stone may form in the pancreatic duct. 

Salivary Calculus. — Phosphate and carbonate of calcium may be de- 
posited in a salivary gland or duct, forming a stone from the size of a grain 
to one of the size of a walnut. 

Rhinoliths always have for a basis some foreign body which has been 
put into the nose or a mass of inspissated mucus. The irritation which 
is set up from their presence causes a precipitation of solids about this 
nucleus. 

CYTODIAGNOSIS, CYTOLYS1S, ETC. 

Cell Diagnosis. — By this term is meant diagnosis by means of the 
chemical and microscopical characteristics of the effusions into the serous 
cavities of the body. 

If we have such a fluid to examine, we note its appearance, color, and 
density, and the presence of fibrin; we analyze it for its chemical composi- 
tion; we examine it with the spectroscope; determine its freezing point 
(cryoscopy), its haemolytic property, its agglutinating properties, and its 
toxicity. We look for bacteria, make cultures, and inoculate animals. 
Microscopically, we note the kind of cell contents. 

In a pleuritic fluid we try to determine if it is from: 1. A tuberculous 
process : a. Primary; b. Secondary to a tuberculosis elsewhere in the body; 
c. Tuberculous hydro pneumothorax. 2. Non-tuberculous process : a. Sep- 
Pneumococcus, streptococcus, bacillus of Eberth, etc.; b. Aseptic — 
Mechanical (cardiac or renal), leucsemic, cancerous, from abscess of the 
liver, syphilis, rheumatism, diphtheria. 

It in the cellular contents we find that the lymphocytes predominate, it 
points to a tuberculous origin; if the multinuclear leucocytes predominate, 
it points to a pneumococcus or streptococcus origin. Simple endothelial 
cells are found in a passive effusion, and cancer cells in some stages of a 
cancerous effusion. It has been found that there are peculiar cell reactions 
to staining agents, so that we can determine whether the cells come from a 
primary or secondary tumor. If there are many tissue cells in a pleuritic 
fluid, we have good reason to suspect the presence of a neoplasm. 

In a peritoneal effusion, we try to determine if it is a mechanical ascites, 



CYTODIAGNOSIS, CYTOLYSIS, HAEMOLYSIS, ETC. 



53 



ascites due to a neoplasm, acute peritonitis, tuberculous peritonitis, or 
fluid from an ovarian cyst. 

In a pericardial eff usion, we try to find whether it is tuberculous or renal. 

In an articular effusion, it may be due to tuberculous hydrarthrosis, 
tuberculous arthritis, rheumatic arthritis, gonorrhceal arthritis, traumatic 
hydrarthrosis, tabetic arthropathy, or synovitis of simple origin. 

In effusions into the tunica vaginalis, it may be from tuberculous hy- 
drocele, gonorrhceal orchitis, typhoid orchitis, traumatic hydrocele, essen- 
tial hydrocele, cyst of the cord. 

We also examine the fluid from skin eruptions as seen in bullae, vesicles, 
and pustules; as herpes, pustules of variola; blister from burning, acci- 
dental or artificial. 

In particular, the examination of the cerebrospinal fluid, obtained by 
lumbar puncture, has been of aid in diagnosis. In the absence of cellular 
elements, we judge that there is no bacterial cause, that the symptoms are 
due to a polyneuritis or a poliamyelitis. When the meninges are affected, 
there are cell elements found. In the beginning of the paralytic period, 
due to a meningitis, when the inflammation is localized, we find a lymphocy- 
tosis, but when the inflammation is extensive, we find a multinuclear 
leucocytosis. 

Cytodiagnosis of the cerebrospinal fluid seems likely occasionally to 
be of great help in distinguishing doubtful cases of paresis and tabes in the 
early stage. " In spinal syphilis, as shown in cases of syphilitic meningo- 
myelitis, as Erb's spinal paralysis, there is an increase in the cell count, 
and if trauma can be excluded, the presence of specific infection may be 
inferred." The activity of the process may be judged also. "If any 
active inflammatory change be going on, polynuclear leucocytes will pre- 
dominate, while in ordinary conditions of specific infection, only mono- 
nuclears are present, with a proportion of polynuclears of not over 5 per 
cent." 

Cytodiagnosis of the cerebrospinal fluid promises to aid us in the diag- 
nosis of tuberculous meningitis, pneumococcus meningitis, meningococcus 
meningitis, streptococcus meningitis, tabes, general paralysis, syphilis of 
the cerebrospinal system, meningo-myelitis, cerebral lesions, sclerose en 
plaques, tetanus, syringomyelia, affections of the peripheral nerves, chorea, 
neuroses epilepsy, mental affections, leucaemia. 

CYTOLYSIS, HAEMOLYSIS, ETC. 

Immunity and serum therapy have received a great deal of study during 
the last few years, and an immense amount of new knowledge has been 
obtained which opens great possibilities. With the exception of the mar- 
velous results from diphtheria and tetanus antitoxine, we have not yet 
been able to apply this knowledge with any great success. When we apply 
the "side chain hypothesis " of Ehrlich, we can formulate the process which 
goes on in the body when one acquires immunity. Lack of space prevents 
a complete consideration of this subject, but a few definitions may aid in 
the understanding of the voluminous literature which has been and is 
appearing. 



51 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



Antitoxins. — By antitoxins we mean substances generated in the fluids 
of the body by stimulation of the cells by irritation from bacterial or 
other toxins. This substance neutralizes the toxin and thus achieves an 
active immunity. If this toxic and antitoxic process takes place first in 
an animal which becomes immune, and the blood serum of this animal is 
injected into the body of a person suffering from the effects of the same 
toxin, we establish in this person a passive immunity. 

Cytolysis is a destruction of cells by some toxic process. 

Haemolysis is a disintegration and destruction of the blood. This takes 
place I hrough the formation of an hemolysin, a substance formed by bacterial 
or other action and capable of destroying the red corpuscles. An hemoly- 
sin is formed in the body of an animal into which red blood corpuscles of 
another animal have been introduced. This hemolysin is capable of dis- 
solving the red blood corpuscles of the animal from which the blood was 
derived. 

Agglutinins are substances formed in the blood as a result of infection 
and capable of causing agglutination or coherence of the bacteria that pro- 
duced the infection. 

Precipitins are formed in a similar manner. If blood serum or exudate 
containing globulin from one animal is introduced into another animal 
of a different species to become adapted, the addition of a little of the 
blood serum of the adapted animal to a dilution of the fluid injected will 
form a precipitate. This reaction is supposed to lead to the identification 
of human blood, and it is hoped, as also it is hoped in these other processes, 
that important features in specific therapy will be discovered. 



CRYOSCOPY 

This word is used to designate the effort to determine the functional 
activity of the kidney by comparing the freezing point of the urine obtained 
l).v ureteral catheterism with that from kidneys known to be normal, and 
with the freezing point of the blood of the patient under observation. The 
principle involved is that a watery solution containing little solid matter 
will freeze at a higher temperature than one containing considerable solid 
matter. We should therefore expect that the urine from a diseased kidney, 
1 1^ eliminative function of which is thus diminished, would freeze at a higher 
temperal ure t han normal ; and that the blood of the same individual, through 
retention <>i solids, would freeze at a lower temperature than normal. 

Much effort has been given to this subject, as it readily can be seen 
thai if an operation is under consideration, particularly upon the kidney, 
it is ol .rreat importance to know the condition of the remaining kidney. 
Kummell makes the following rule in cryoscopy: "The freezing point of 
normal blood is-0.56° C. or higher; of normal urine,-0.9° C. or lower. 
A freezing poinl of the blood of -0.58° C. or lower, or a freezing point of the 
unne ol 8° ('., shows a degree of renal impairment which makes opera- 
tions upon the kidney dangerous and unjustifiable." 

" fhe following propositions have been emphasized: 1. The freezing 
point of the Mood, notably depressed in cases of renal sclerosis, can be raised 
i" the presence of chronic parenchymatous nephritis, 2. The freezing point 



DIRECTIONS FOR PREPARING SPECIMENS 



55 



of the urine, which may be normal or slightly elevated in parenchymatous 
nephritis, is much higher in cases of renal sclerosis, even approximating that 
of the blood serum itself. Hence, 3. Inferences as to the condition of 
the kidneys are justified only by a consideration of the freezing point of 
both fluids, as well as of the total quantity of urine." 

"Uraemia, renal insufficiency, and renal permeability must be carefully 
distinguished ; they do not vary in constant ratio one with another. Urae- 
mia can coexist with permeable kidneys." 

Test : The test is simple. All that is required is a centrigrade thermom- 
eter, a large test tube, and a freezing mixture of ice and salt in a wide necked 
glass bottle. Two ounces of blood are drawn from the medium basilic 
vein with a cannula into the glass tube. Coagulation is prevented by 
constant agitation. The tube and thermometer are immersed in the freezing 
mixture. The freezing point of normal blood is 0.56° C. to 0.57° C. This 
test is made prior to a contemplated nephrectomy. A freezing point of 
0.59° C. demands caution. A freezing point of 0.60° C. is a positive 
contraindication to any operative interference on the kidney (Kummell, 
of Hamburg). Cryoscopy in connection with cystoscopy, segregation of 
urines, and the phloridzin test is to be regarded only as an aid to diagnosis 
— the examination should be prolonged over a number of days. (See also 
Renal Insufficiency.) 

Kapsammer has observed that the freezing point of urine may be in- 
fluenced by reflex polyuria from catheterism of the ureters. The result 
of this new method should be accepted cautiously. 

PHLORIDZIN 

Normal kidneys, according to present information, permit of the prompt 
transformation of phloridzin, injected subcutaneously, into sugar, while 
diseased kidneys fail to accomplish this transformation just in proportion 
to the lesion of the secreting cells. 

Caspar and Richter emphasize, as a preliminary to operation in cases 
of suspected renal insufficiency, the importance of estimating three factors — 
the quantity of urea excretion, the amount of sugar excretion after injection 
of phloridzin, and cryoscopy. They express the utmost confidence in the 
conclusions based upon these premises. 

DIRECTIONS FOR PREPARING SPECIMENS 

Serum Culture for Diphtheria. — Rub the cotton gently but freely against 
any visible throat exudate and subsequently rub the swab thoroughly 
over the surface of the blood serum. Do not allow the swab to touch any- 
thing but the throat and the serum. 

Urine. — Collect in a clean glass. To preserve it, add a few drops of 
chloroform or crystals of thymol. 

Sputum. — Collect and send in clean wide mouthed bottles. 

Blood. — For the malaria test. After carefully washing, prick the lobule 
of the ear or the tip of the finger, wipe away the first drop of blood, catch 
a minute drop of blood on a clean cover glass, cover the same lightly with 
a second glass, draw them quickly apart, and allow to dry. 



50 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



Widal Test. — Place several separate drops of blood on a slide and allow 
them to dry without spreading. 

Red and white blood corpuscles can only be counted in a specimen 
accurately diluted. To determine the haemoglobin, use Tallquist's blotting 
paper at the bedside. 

Tumors and scrapings can be preserved in a 2 per cent solution of for- 
malin in sterile bottles. 



CHAPTER II 



GENERAL THERAPEUTIC MANAGEMENT 

Synopsis: Fever Diet. — Convalescent Diet. — Nutrient Enemata. — Subcutaneous Alimen- 
tation. — Gavage. — Lavage. — Low and High Flushing of the Colon and Colon Inflation. 
■ — Antipyresis by Medication. — Hydrotherapy, Baths, Packs, Douches. — Balneothera- 
peutics. — Stimulation. — Cold Air. — Enteroclysis. — Apparatus for Infusion and Hy- 
podermoclysis. — Drug Stimulation. — Management of Dyspeptic Symptoms. — Coated 
Tongue, Nausea, Vomiting, Thirst, etc. — Laxatives. — Diaphoretics and Diuretics. — 
Expectorants, Cough Mixtures, Inhalations. — Dyspnoea. — Pain in Acute and Chronic 
Illness. — Nervousness. — Insomnia in the Absence of Pain. — Counter Irritants and 
External Applications. — Venesection and Local Depletion. — Nasopharyngeal Toilet. 
— Tonics in Convalescent Stage. — Remarks on Mental Therapeutics. — Dose Deter- 
mination. — Practical Rules and Tables for Converting Apothecaries' Weight into 
that of the Metric System. — Invalid Bed. 

INTRODUCTORY REMARKS 

Therapeutics is the treatment of disease, not by medicines alone, but 
by any and all means and appliances. The only reliable basis of thera- 
peutical knowledge is clinical experience. 

The general therapeutic management embraces the treatment of symp- 
toms and conditions usually met with in acute and chronic ailments. 

In the absence of specific medication, which at the present time we have 
only for a very few diseases (diphtheria, malaria, syphilis, etc.), the manage- 
ment of acute febrile diseases is mainly hygienic and dietetic, coupled with 
the employment of rational antipyretic measures, timely stimulation, 
and careful attention to annoying or grave symptoms. 

The similarity of treatment particularly in all acute febrile affections 
makes it advisable, in order to avoid repetition, to discuss the general 
therapy in this separate chapter, to which the reader will be referred as the 
various diseases come under consideration. 

FEEDING IN SICKNESS 

Fever Diet. — A so called fever diet is essential in all febrile diseases 
or conditions. The food should be fluid or semisolid, so as not to overtax 
the feeble digestive apparatus or leave a large residue in the intestine for 
decomposition, which would be apt to favor autointoxication or local 
irritation. 

The attending physician will do well to write out a diet on a prescription 
blank or on the history chart to be kept by the nurse, and he may select 
from the list of liquid and soft diets to be found in the chapter on Nutrition 

57 



58 



GENERAL THERAPEUTIC MANAGEMENT 



and Diet such articles as the patient may naturally desire, the list having 
been compiled with a view of meeting the demands of the adult sick. 

Breast fed or bottle fed children when ailing will naturally take less 
food than in health, particularly if kept in ill ventilated, hot, and stuffy 
rooms: hut they will not require a change of food except in diarrheal 
diseases. A dilution of their ordinary bottle food or a longer interval 
between feedings is therefore indicated, and no special concern need be 
entertained if the little patient refuses to take its usual quantity of food. 

Moiled water should be offered to adults and children to quench thirst 
and favor excretion and elimination by skin discharges, the quantity of 
water to he given depending upon the requirements of each individual 
case. As pure water is not poisonous, it will never do harm. This rather 
superfluous remark is made for the encouragement of colleagues addicted 
tot he drugging evil and more ready to prescribe drugs than to offer water. 

Special Diets.— For children who no longer take the bottle, we may 
selecl food from the following list: Water, toast water, farinaceous water, 
gum arabic water, white of egg in water, peppermint tea, imported ginger 
ale, black tea, milk, matzoon, kumyss, buttermilk, whey, sterilized, 
Pasteurized, peptonized, or malted milk, beef broth, mutton broth, 
chicken broth with and without egg, beef jelly, soups, gruels, corn- 
starch pap, pea soup, burnt flour, soup, eggnogg, tropon or somatose 
in peppermint tea, custard, ice cream, water ices, orange or pineapple 
juice, unfermented grape juice, champagne, California Tokay wine, whiskey 
in water. 

Milk is contraindicated in dyspeptic and inflammatory diarrhoeas and 
in cases of milk idiosyncrasy, and also in cases of typhoid fever when the 
abdomen is markedly tympanitic. When milk is contraindicated, the fol- 
lowing articles on the list may be offered: Water, toast water, farinaceous 
water, black tea, gum arabic in water, white of egg in water, beef or mutton 
broth and egg, pea soup, and burnt flour soup. The latter is particularly 
useful in diarrhoea! disorders. 

An exclusive milk diet is indicated for infants up to eight months, and 
many practitioners favor an exclusive milk diet in cases of typhoid fever, 
in acute and chronic Bright 's disease, in acute pyelitis, in chronic gastric 
catarrh, in gastric ulcer and cancer, in scarlatina, in neurasthenia, and in 
the Weir Mitchell rest cure. The writer is not convinced that a rigid milk 
regimen is superior to a more liberal bland mixed liquid diet. 

Peptonized Milk and Meat. — Peptonized food or predigested food is some- 
times serviceable when the digestive power is feeble, but in children it is 
lent I y ordered unnecessarily and in cases in which it is positively 
harmful, as it adds to the intestinal putrefaction. This is particularly 
true when it is used for a long time. Under no circumstances should it 
he employed other than as a temporary makeshift. 

The writer seldom employs peptonized milk for children, and much 
prefers to aid digestion by administering a few drops of hydrochloric acid 
in sugar water after eating. 

Sarcopeptones, or Beef Peptonoids.— These are sometimes useful to 
tide over a critical period. If given for any length of time, they favor 
a putrid condition of the gastroenteric tract. Beef or sarcopeptones are 



RECTAL ALIMENTATION— NUTRIENT ENEMATA 



59 



obtainable in the shops in a liquid or semisolid form, or they may be pre- 
pared by treating beef with an extract of pancreas, which is prepared by 
macerating for one week the pancreas of a pig, calf, or sheep with four times 
its weight of 50 per cent alcohol and filtering. 



Feeding by the rectum is useful in feeble digestion and in cases in which 
food is not tolerated by the stomach, or to supplement a feeble stomach 
or inability to swallow, or in gastric ulcer and incessant vomiting, also 
in the insane. Before injecting food into the rectum, the latter should be 
cleaned by an enema. The patient is placed on the back with the thighs 
elevated, and a rubber tube of proper length is inserted into the rectum 
as far as it will go. The fluid food, consisting of an artificial fat emulsion 
or of milk or gruel with egg, whiskey, or peptonized food or somatose in 
watery solution, is allowed to flow into the rectum from an irrigator or 
fountain syringe. Various medicinal substances may be added to the enema 
if desired. Children will retain from two to eight ounces, and adults up to 
a pint. When the rectal tube is withdrawn, the buttocks may be pressed 
together to prevent the escape of fluid. 

Feeding in infectious fevers is a matter not clearly understood, for we 
practically know nothing regarding the difference in the behavior of mi- 
crobes in a starving and in a well nourished body. A child of seven, re- 
quiring a daily food value of 1,400 calories in health, probably takes only 
half a pint of eggnogg or one pint of milk in twenty-four hours when sick 
and feverish (which latter is equal to 400 calories), as in septic scarlatina 
with diphtheria, and rapidly emaciates, while some children take nothing 
or vomit everything given them. Now, the question is: Shall we let Nature 
take her course for a few days, or shall we endeavor to feed the body by 
nutrient enemata? As the body fat is first burnt up in fever, we may wait 
a certain time, but not too long. Nutrient enemata are poorly absorbed; 
therefore we must not expect too much from rectal alimentation, for it will 
have but little influence in counteracting the pernicious action of bacterial 
products or toxins on the nerve centres. 

Subcutaneous feeding has been adopted to tide the patient over 
a critical period. The following formula has been used: 



This to be injected under the skin in divided doses in twenty-four hours 
in severe cases of gastric ulcer or intestinal obstruction. Reports on the 
value of subcutaneous feeding are not encouraging. 

A preparation containing soluble albumin and table salt sold under 
the name of kalodol may be resorted to for subcutaneous feeding. 

Diet in the Convalescent Stage. — In the convalescent stage a liquid and 
soft diet may be selected from the list given in the chapter on Nutrition and 
Diet, with due consideration of the patient's natural likes and dislikes. 



RECTAL ALIMENTATION— NUTRIENT ENEMATA 



Grape sugar, . . 
Table salt, .... 
Pepsin peptone 
Water, 




ad. 



GO 



GENERAL THERAPEUTIC MANAGEMENT 



In the case of breast fed and bottle fed children, we gradually return to 
the food given when the child was in good health, unless the former method 
of feeding was faulty, in which case we select the proper food (see Infant 
Feeding). Older children may take in addition to their milk some of the 
following articles: Well cooked cereals, cornstarch pap, bread pudding, 

scrambled eggs, apple sauce, 
baked apples, scraped meat, 
calf's foot jelly, beef jelly, milk 
toast, sponge cake, biscuit, 
bread, zwieback, etc. 

GAVAGE 

Feeding by the stomach tube 
is accomplished by means of a 
soft catheter (No. 12 to 14) and 
a glass receptacle (a funnel of 8 
oz. capacity), as shown in the 
cut. Adults require a large tube 
and funnel. In rebellious pa- 
tients a mouth gag should be 
used, or the tube may be intro- 
duced through the nostril. 

Indications for Gavage. — L 
When patients refuse to take 
food, as in septic fever and 
coma, when rectal alimentation 
is inadequate. 2. In intubation 
cases when children cannot 
swallow or refuse to swallow. 
3. In habitual vomiting. Ba- 
bies are sometimes unable to 
retain food which is swallowed, but manage to keep it down when given 
by gavage. 4. In premature infants and cases of malnutrition. 

As soon as the food is in the stomach, the soft tube is pinched with the 
thumb and forefinger and rapidly withdrawn. The infant is not taken up 
until some time has elapsed, to prevent vomiting or regurgitation. In 
an infected stomach, lavage should precede gavage. 

FLUSHING THE STOMACH AND BOWELS 

Stomach Washing — Lavage 
The most convenient and at the same time thorough way of washing 
imach is by means of the apparatus shown in the illustration. For 
children s Fountain syringe is attached to a glass T cannula which has a 
flexible catheter at one end and a waste tube at the other. Adults swallow 
a 90fl rubber stomach lube— the wash water is introduced by means of a 
large funnel, which when lowered allows the fluid to return by siphon 
action. The stomach tube for adults is two feet long and joined to the 




Fig. 16. — Gavage. 
Feeding by means of the stomach tube. 



FLUSHING THE STOMACH AND BOWELS 



Gl 



rubber tubing by means of a glass cannula. The funnel holds one pint. 
One or two funnelfuls are let in at a time and siphoned out by lowering the 
funnel. A return flow will be inter- 



fered with if the tube is bent upon 
itself or above the level of the fluid 
or blocked by food, etc. 

Two to four quarts of boiled luke- 
warm water in which a tablespoon- 
ful of sodium bicarbonate has been 
dissolved may be used at one sit- 
ting. Weak persons should be treated 
in bed. 




Average distance, 55 to 60 cm. Fig. 17. — Soft Rubber Stomach Tube. 

from the teeth. Contraindications: 

Heart disease (advanced), aneurysm, recent haemorrhages, including apo- 
plexy, advanced pulmonary disease, ulcer with recent haemorrhage. 
These rules do not hold good for all emergencies. 

In case of necessity the tube can be introduced through the nostril, 




Fig. 18. — Stomach Washing in Adults. 



(>2 



CKXKKAL THERAPEUTIC MANAGEMENT 



i 





r 



in which position it will not be possible for any unruly child or insane 

adult to bite it. , 

The child is held upright in the nurse's lap with the head secured m 
a forward position to allow saliva and vomited matter to escape by the 

mouth. In introducing the tube 
there is a slight hitch at the en- 
trance of the oesophagus, but it 
is easily overcome. When the 
tube is too large, it will com- 
press the larynx, and young 
children appear flushed and 
slightly cyanotic. When the 
clear cry of the child is heard, 
we know that the tube is not in 
the larynx. In letting in the 
water the stomach must not be 
filled to overflowing, unless it is 
necessary to expel large curds 
which would not go through the 
catheter No. 12 or 14. Over- 
flowing the stomach is safe only 
when the child's body is bent 
forward or it lies on its side. 
Stomach washing is an easy 
procedure in infants and chil- 
dren under two years. Stom- 
ach washing may also be accom- 
plished by means of swallowing 
warm water in the ordinary way 
and inducing vomiting by irritating the pharynx by the introduction of 
the fingers into the throat. 

Stomach washing in children is occasionally indicated: In acute gastritis, 
in acute poisoning, in cholera infantum, in chronic indigestion with atony 
of the stomach (to remove undigested 
food and foreign matters), in difficult feed- 
ing cases, in persistent vomiting, and 
previous to operations on the stomach. 

When it is necessary to simply clear 
the stomach of its irritating contents, a 
si n ude washing is sufficient. In chronic 
cases washing every other day is neces- 
sary. The irrigation fluid is boiled water 
at the temperature of the body. Occa- 
sionally it is well to add a teaspoonful 

of bicarbonate of sodium to a pint of water to make it alkaline 
is contraindicatcd in collapse. 



Fig. 19. — Stomach Washing in Infants by 
means of a fountain syringe, at an eleva- 
TION of Foun Feet. 

A T cannula connects reservoir stomach tube and 
waste pipe. 




Fig. 



20. — T Cannula 

TION. 



for Irriga- 



Gavage 



LOW AND HIGH ENEMATA AND COLON INFLATION 



63 



Enteroclysis — Low and High Enemata and Colon Inflation 

Flushing the colon in children and adults is accomplished by means of 
a soft rectal tube in the manner shown in the cut (soft rubber irrigating 
tube and a fountain syringe). 

The colon may be distended with boiled water, medicated water, starch 
water, soap suds, oil, air (by bicycle pump inflation), or carbonic acid gas 
(from an inverted siphon). Liquids as a rule do not penetrate farther than 




Fig. 21. — Bowel Irrigation in Infants and Children. 



the ileocsecal valve, but indirectly the entire gut will profit by lavage, by 
bringing down the contents from the small intestine and clearing the colon 
of putrid material. The value of irrigation depends somewhat upon the 
absorption of water by the large intestine. 

High Enemata. — The high enema is administered through a long cath- 
eter (colon tube) attached to a fountain syringe: To secure bowel action 
(use soap suds water, one half to two pints at a temperature of 101°-103° F.) ; 
to stimulate in circulatory failure; to prevent shock and collapse before 
chloroform anaesthesia, and before and after operations; in renal insuffi- 
ciency, uraemia (irrigate for twenty minutes at 110° with Kemp's flexible 



C>4 



GENERAL THERAPEUTIC MANAGEMENT 



tube) ; m jaundice (irrigate with cold water at 60° or warm water at 110° 
F.) ; to reduce temperature (irrigate at 60°, 70°, 80°, or 90° F. Cold irriga- 
, ions depress the heart); to replace lost fluids (irrigate at 110° F. as in weak- 
ness from hemorrhage) ; to overcome intestinal obstruction ; to nourish 
per rectum. 

Low Enemata are given with a short tube and have about the same 
indicat inns as high injections, but are not quite so effective. They are some- 
times useful in subacute local inflammations of pelvic organs, but are or- 




Fig. 22. — Kemp's Rectal Irrigator (Double Current Catheter). 

dinarily employed to secure bowel action. Colon Inflation by means of 
medicated water, oil, or gas, is practised to overcome bowel obstruction, 
and will be discussed more fully in the chapter on Intussusception. 

ANTIPYRETIC MEASURES 

Fever is characterized by a rise of temperature plus a disturbed metab- 
olism. A normal temperature is maintained by a complicated system of 
heat regulating apparatus, the details of which are more of physiological 
than of clinical import. An increase of temperature is usually accom- 
panied by increased frequency of respiration. In fever there is a con- 
traction of surface capillaries; the skin cools off and the patient experiences 
a chilly feeling. Occasionally chills are observed with a high temperature, 
a reddened skin, and distended capillaries. A nervous chill is accompanied 
by no rise in temperature. In order to produce fever by infection, bacteria 
or other products must actually enter the circulation. The same holds 
good for Protozoa (malaria). We have no definite knowledge regarding 
the purely nervous irritation of the heat centres. The predisposition to 
high temperature varies with the individual and his age and condition. 
5foung and strong individuals have a higher range of fever heat than the 
weak and aged. As a rule a continued high temperature is accompanied 
by loss of appetite and by inanition. Here again there are exceptions. 
The writer lias known children and adults to have a temperature of 104° 
for over a week, though still an excellent appetite. 

The significance of lexer for the organism is still a mooted question. 
On the one side fever is looked upon as a direct danger, and contrawise 
a high temperature is looked upon as favoring a limitation of diseased 
conditions. In many instances the thermometer has proved a stumbling 
block instead of an aid in practice, and even intelligent practitioners are 
frequently made uneasy by a rise of temperature in a patient, and resort to 
"premature antipyretic measures," thereby distorting the clinical picture 
of an ailment the nature of which is still in doubt. 



ANTIPYRETIC MEASURES 



65 



Naturally our therapeutic efforts will vary according to our personal 
conception of such conditions. At the present time we are still in the dark 
regarding these points, and we do not exactly know whether fever due to 
infection is favorable or unfavorable to the animal economy. 

Our knowledge of subnormal temperature is meagre. Subnormal 
temperatures are not uncommon, and a continued subnormal temperature 
is a grave symptom, particularly in diseases usually characterized by high 
fever. Thus our antipyretic measures or efforts by means of hydrotherapy 
or chemical antipyretics may or may not be of value in a given case, but 
are probably rational as favoring increased elimination. 

DRUG ANTIPYRETICS 

Quinine as an antipyretic is indicated only in malarial fever. It is 
useless and often dangerous to depress the temperature by large doses of 
quinine in any other class of cases. 

Antipyrine, phenacetine, acetanilide, and lactophenine, also citrophen, 
may be used occasionally, one or two doses in the evening, when the tem- 
perature is at its highest, in order to reduce it for a few hours and overcome 
if possible the cerebral restlessness which makes' sleep" impossible. The 
routine and frequent administration of antipyretics as soon as the tem- 
perature reaches 103° is bad practice. 

Quinine Saccharinate (sweet quinine). — This new. quinine product is 
now obtainable. It contains 67 per cent of the alkaloid and is therefore 
quite as efficient as the sulphate. It comes in crystal form or in compressed 
tablets, and is destined to take the place of the ordinary bitter quinine 
preparations. The dose is the same as that of the sulphate. Euquinine 
is a tasteless quinine preparation of about the strength of the sulphate, 
and has the same therapeutic indications. 

Quinine Sulphate (hydrochloride). — Dosage: Antipyretic dose, gr. 3 
to 15, suspended in compound elixir of taraxacum or in honey or given in 
a wafer. 

Antipyrine (soluble in water). — For children, single dose, gr. 1 to 3; for 
adults, gr. 5 to 15. Also per rectum in double dose. 

Phenacetine (insoluble in water). — Sedative and antipyretic, gr. 5 to 15 
for adults; gr. 1 to 3 for children, several times a day. 

Lactophenine (somewhat soluble in water). — Sedative, antipyretic; dose, 
gr. 5 to 15 for adults; gr. 2 to 3 for children, several times a day. 

Citrophen. — Same indications and dosage as phenacetine. 

Acetanilide (antif ebrin) . — Dose, gr. \ to 2 for children; gr. 3 to 10 for 
adults, several times a day. 

HYDROTHERAPY, BALNEOTHERAPEUTICS 

Hydrotherapy plays a most important role in the management of acute 
and chronic illness by reason of the antipyretic and stimulating effects of 
baths, packs, and douches. The " hydrotherapeutic reaction " is the natural 
reaction of the body to heat or to cold. The temperature of the water 
should not be much above or below 90° F. 
6 



(>(> 



GENERAL THERAPEUTIC MANAGEMENT 



The Cold Bath. — When a person plunges into cold water or has a 
cold douche applied over a considerable area, he shivers and then takes 
a deep inspiration. The skin is cold and pale, but upon his leaving the 
water, if the reaction is present, it becomes red, and he feels a sense of 
warmth and breathes more easily. Voluntary motions, friction of the skin, 
and the general health and strength of the individual, as well as the tem- 
perature of the water, the length of the bath, and the force of the douche, 
govern the degree of the reaction. To one accustomed to the initial shock 
it is agreeable, and the reaction is more easily obtained. The flow of urine 
is increased, the action of the bowels is promoted, the appetite is. stimulated, 
digestion is aided, and the nervous and muscular systems are toned up. 

The Warm Bath is sedative. The superficial vessels are dilated and 
t here is a sensation of warmth. The respirations are increased in frequencv. 




Fig. 23.— Hot Pack. 

Perspiration is increased. The sedative action is shown by the desire after- 
u:ir ' 1 for res1 and repose, while the effects of a cold bath are just the op- 
P° site ,1, >in ' and ability for physical exertion, an increased energy. 
Il"t applications tend to make one constipated. 

Hoi air ami hot vapor baths differ from hot water baths in favoring 
perspiration. One perspires most in hot air baths. 

Douche.— Douche is a term used to indicate a bath where a stream, 
the size ol which may differ, is directed against some part of the body. 
J he lon e u -11 h which it strikes the body acts as a powerful stimulant. It 
is usually directed against the back, along the spinal column. 

I i Rkish Baths are really dry hot air baths combined with a shampoo, 
massage, and cleansing. The temperature is raised to about 150° F. and 
sometimes higher. 



HYDROTHERAPY, BALNEOTHERAPEUTICS 



67 



Russian Baths are exposures of the body to hot aqueous vapor, and 
the temperature of the room is often raised to 150° F. After the shampoo, 
massage, etc., the bather is subjected to a very cold douche. 

The Permanent Bath, or Hebra's Water Bed, is used for many 
skin diseases and other conditions. A tub long enough and deep enough to 
accommodate the prone body is arranged on legs like a bed, and a woven 
wire support upon which the patient lies is arranged on cogs so that it 
can be raised or lowered into the tub without disturbing him. A head 
rest is provided, so that the patient's head may be out of the water. In 
some cases the patient is left in the water continuously for months. The 
water should be warm, of about the temperature of the body, and it is 
changed by means of entrance and exit facilities about three times in twenty- 
four hours. The water may be medicated. In general it is employed for 
those conditions where a large surface is denuded of epithelium, as in 
ulcerative syphilides, psoriasis universalis, pemphigus foliaceus, dermatitis 
exfoliativa, lichen ruber acuminatus universalis, pityriasis rubra univer- 
salis, icthyosis, etc. In burns or injuries from freezing, gangrene, diabetes, 
endarteritis obliterans, phlegmon, urinary infiltration, decubitus, spondyl- 
itis, caries, etc., the permanent bath is of great benefit. 

Baths properly applied exert a tonic, eliminative, and antipyretic action. 

Mustard Bath. — An ounce of mustard is tied up in a muslin bag and 
thrown into the bath. The water may be of any temperature desired, 
105°, 100°, or 80°. 

The Cold Douche is not adapted for feeble cases. It is useful as a 
heart and nerve tonic. The patient stands in warm water and a pitcher 
of cold water (60°) is dashed over his back, after which he is rapidly dried 
and placed on a couch to rest. 

The Hot Pack is used in uraemia. The patient is wrapped in a sheet 
wrung out of water at 110°, and then in a blanket. This may be changed 
every half hour. 

Hot Bath. — The patient is placed in a bath at 100°, with cold applica- 
tions to the head. It is useful in collapse and to promote elimination by 
the skin. 

Hot Vapor Bath. — Hot air or vapor is introduced under the raised 
bed clothes from a croup kettle for twenty to thirty minutes. 

The Wet Pack (Priesnitz). — The bed is protected by a rubber sheet- 
ing, and a large Turkish towel wrung out of cold water is spread out in such 
a manner that when the patient is laid with his back upon the wet towel 
and wrapped up in the towel the trunk will be covered and the extremities 
and head free. The patient is then covered up to the neck with a woolen 
blanket. The wet pack can be changed every half hour or hour or two 
hours. 

Cool Sponging must be done under cover, or in a room heated to 80°, 
with alcohol and water or vinegar and water equal parts. Sponge from 
ten to twenty minutes to reduce the temperature and restlessness. The 
wet pack and cool sponging are the favorite hydrotherapeutic measures of 
the author in cases of children. 

The Cold Pack is for reducing persistent high temperature with 
delirium. The patient is enveloped in a sheet wrung out of warm water, 



GENERAL THERAPEUTIC MANAGEMENT 



and ice is rubbed over the entire covered body, while he lies upon a 
blanket in a bed protected by a rubber sheet. He may remain in the wet 
pack and the rubbing with ice be repeated as often as necessary. Hot 
i ha^s may be placed at the feet. This is to be employed only in 
extreme cases for adults and children. 

Warm a nd Cold Baths. — The patient is put into a bath at 100° and the 
water is gradually cooled to 80°, the trunk and extremities being rubbed 
while he is in the water or stimulated with hot water and whiskey. The 
bath may last from ten to twenty minutes. To prevent chilling, the tub 
may l>e covered with a blanket having a slit for the head to go through. 
It is for cases with persistent high temperatures with delirium. 

The Sheet Bath. — Where objection is made to the full bath, we 
make use of the "sheet bath," beginning with a temperature of 100° F. 
for children or 90° for adults. An old linen sheet or tablecloth should be 
used, and it should be wrung out very lightly. The patient having been 
wrapped in this, water at a temperature about ten degrees lower should be 
poured successively upon different parts of the body, and each part rubbed 
with the hands until it no longer warms up. 

The Ice Cap and Cold Coil are often efficacious in reducing tem- 
perature and restlessness in infants. They may be used continuously 
or intermittently, together with irrigation of the colon. 

Ice Poultice. — Cracked ice with bran or sawdust is wrapped in oiled 
silk or rubber cloth. The indications are the same as for the ice cap. 

Cold baths and cold packs should be employed with great caution and 
good judgment in. infective fevers of children. Cool sponge baths, with or 
without alcohol, are stimulating and not depressing, and if supplemented 
by an ice cap or ice coil and flushing of the colon with cool water, will cer- 
tainly do no harm. A more decided antipyretic effect is accomplished by 
i ubbing a child at 100° and gradually reducing the temperature of the water 
1 1 1 S " J or 70° and applying friction at the same time. 

A warm mustard hath at 90° or 100° F. is well borne by feverish children 
and is an excellent means of starting or favoring elimination. In urgent 
cases in which a continued high temperature is the grave feature, the pro- 
longed or permanent bath is advisable, starting at 100° and reducing to 80° 
or 70°, and leaving the patient immersed for twenty to forty minutes. 
Tin- writer lias never seen ill results follow the cool pack by means of a sheet 
wrung out of cold water and applied all around the body from the armpits 
to the pelvis under a blanket. The extreme heroic application of cold 

1 r, either in the shape of tubbing or the cold pack with ice or snow, 

in the author's opinion an unsafe procedure in children and in adults 
as well. 

BALNEOTHERAPEUTICS 

The drinking of much water tends to increase the watery secretions 
" f ""' Dod y. sucn :1S the urine, bile, saliva, pancreatic juice, and sweat. It 
thus aids in the excretion of the waste products. The benefit derived from 
t he courses of mineral waters in a large measure is due to the liberal quan- 
consumed. Clout, urinary gravel, imperfect secretions of bile, 
constipation, etc., are conditions benefited thereby. (See also chapter on 
Nutrition and Diet.) 



STIMULATION 



69 



COLD AIR 

Inspirations of Cold Air in Fevers. — According to clinical experience, 
cold air inspirations have a positive value in febrile affections. Patients 
breathing cold air (adults and children) have a better digestion and 
sleep better than those in heated rooms. The phenomena of bronchial 
catarrh decrease to a marked degree under the influence of cold air inspira- 
tions, and the general course of 
disease appears to be favorably 
influenced. 

Antipyresis by drinking large 
quantities of cold water, in con- 
nection with cool water entero- 
clysis and keeping open the win- 
dows of the room day and 
night, has given excellent results 
in cases of typhus and typhoid 
fever. Both these methods of 
antipyresis increase the quan- 
tity of urine and diminish its 
specific gravity, especially the 
drinking of water. Thus the 
internal organs, which have the 
highest temperature during fe- 
ver, are cooled, and the tissues 
are permeated and cleaned by 
the water and freed of pto- 
maines. 



STIMULATION 

When the physician suspects 
or recognizes circulatory failure, 
he resorts to methods of stimu- 
lation, as with alcohol, drugs, 

or enteroclysis and baths. When circulatory failure is due to shock or loss 
of blood (when an individual bleeds into his own blood vessels from vaso- 
motor paralysis) , the surgeon relies more upon hypodermoclysis and venous 
infusion than upon drugs. In the so called weak heart in acute infectious 
fevers, we have no clear conception of the exact nature of the circulatory 
failure, and at the bedside we are generally unable to determine whether 
heart weakness or vasomotor paralysis or both are present, and hence the 
choice of stimulants in a critical and grave case is not an easy matter. 
Laboratory experiments on animals poisoned with toxines have demon- 
strated that circulatory embarrassment, heretofore attributed to cardiac 
weakness, is due mainly to vasomotor paralysis, particularly in the early 
stages, whereas the late circulatory failure, in diphtheria for instance, 
appears to be due to cardiac weakness. In medical practice, and particularly 




Fig. 24. — Enteroclysis. 



70 



GENERAL THERAPEUTIC MANAGEMENT 



among children, drug stimulation and reflex nerve stimulation by means 
of cool water are almost exclusively relied upon. 

A moderate rise of pulse and temperature appears to be the indication 
for the administration of the various heart drugs in use at the present 
time. It is questionable whether early stimulation or promiscuous stimu- 
lation is in the interest of the patient. Unfortunately the indications for 
stimulation are by no means clearly understood, and no doubt in many 
instances we credit happy results to some particular drug or method when 
the inherent reserve power of the heart alone is responsible for the recovery 
of the patient. In view of the many disappointments and failures which 




4 



Fig. 25. — Hypodermoclysis. 



we encounter in our attempts to keep the circulation going, there arises 
this very important question: Is stimulation by means of enteroclysis, 
hypodermoclysis, and venous infusion as effective and as safe in sepsis as 
in surgical shock, and in what class of cases may we employ them? The 
problem will be solved by clinicians at the bed-side. 

In June, 1903, at a meeting of the American Pajdiatric Society in Boston, 
the writer reported some observations bearing on this question from his 
hospital experience in cases of pneumonic, typhoid, diphtheritic, and 
puerperal sepsis, of which the following is a resume. 

From the study of the effects of saline infusion in shock and hemorrhage, 



DRUG STIMULATION. 



71 



it would appear that this procedure and also hypodermoclysis 1 may be re- 
lied upon to promptly and safely stimulate in circulatory failure. And it is 
safe to continue with the saline until the pulse is of good quality. From a 
study of the septic cases treated by saline infusion it would appear that in 
order to remain on safe ground, it should be used for septic cases in which 
there has been a decided loss of fluids, as in cholera or typhoid diarrhoea. 
In cases of sepsis without loss of fluids, with an imperceptible pulse and 
rapid respiration in conjunction with a rapidly thumping and undilated 
heart, an infusion or hypodermoclysis may be warranted, but under no 
circumstances should these methods be employed in a routine way. 

Enteroclysis. — Enteroclysis, or flushing of the colon with a saline at 
110°, is an absolutely safe method of combating circulatory failure in septic 
conditions. It stimulates kidney secretion and promotes the elimination 
of poisons. It induces intestinal absorption of water when the body craves 
it, has a certain effect in reducing temperature, and is indicated as a routine 
treatment in all septic conditions even if the kidney is not involved. In 
severe anaemias the writer has found that enteroclysis is followed by an 
actual improvement of the constitution of the blood independently of the 
administration of drugs, such as iron or arsenic. 

Enteroclysis is performed by means of a long flexible tube and a fountain 
syringe, or by means of a double current flexible tube (Kemp's method). 
A tablespoonful of salt is dissolved in two quarts of water at 100° to 110°, 
and by elevating or lowering the fountain syringe the water is made to flow 
slowly into the bowel. In order to be effective, this must be kept up from 
thirty to sixty minutes and carried out by a trained nurse or by the physician 
himself. Enteroclysis should be universally adopted as a therapeutic 
measure of great value, and it may be used in connection with drugs, 
baths, etc. 

The advantage of enteroclysis over venous infusion in sepsis lies in its 
safety. When the heart muscle is weakened by the septic and febrile proc- 
ess, it is dangerous to suddenly increase the blood pressure, and there is 
also danger of carrying thrombi to other parts. The absorption of fluids 
from the intestine can only be slow and gradual, and not more can be 
absorbed than the organism craves. 

In general practice enteroclysis is readily possible, and hypodermoclysis 
or infusion demands a sterile manipulation which is often difficult to obtain. 
Enteroclysis should be our routine method in typhoid, smallpox, scarlet 
fever, measles, diphtheria, cholera infantum, eclampsia, and anaemia. 

Drug Stimulation 

We often administer drugs for the purpose of stimulation, such as 
alcohol, camphor, strychnine, nitroglycerine, digitalis, and ammonia, and 
also in connection with the cool douche or cold pack, with a view of effecting 
a reflex nerve stimulation. 

Alcohol. — The conclusion seems to be that, while alcohol cannot build 
up the body, it does serve as fuel to the body, and at the same time it is 

'The subcutaneous injection of a decinormal salt solution, 3vj of sterilized salt to 
one gallon of sterilized water at 100° to 120° F. 



72 



GENERAL THERAPEUTIC MANAGEMENT 



capable to a certain degree of stimulating respiration. It is therefore 
of value in febrile disease and often aids to prolong life. 

In a general way, we may say that 



May be administered in twenty-four hours. 

Children take from five drops to a teaspoonful of whiskey in water at a 
time. Mild stimulants, such as coffee, black tea, and hot beef tea, may 
be given in connection with or instead of alcohol. Adults may require 
much larger quantities. 

Other drugs used are ether (spir. aether, comp.), gtts. 2 to 20 on sugar; 
ammonia (spir. ammon. arom.), gtts. 5 to 15 in sugar water; camphor, 
powder, or oil; digitalis powder, infusion, tincture, fluid extract; strychnine; 
nitroglycerine; caffeine. 

Strychnine, gr. -sV-gV; nitroglycerine, gr. tot - "5t every three hours; caf- 
feine and sodium benzoate, gr. iij every three hours; camphor in oil (1-15) 
is a powerful stimulant and expectorant. Five to ten drops may be 
injected subcutaneously every three hours. 

When the stomach is not rebellious we obtain satisfactory results 
from 



Timely and judicious stimulation is important in the management of 
disease conditions. Overstimulation is to be avoided, particularly over- 
stimulation by drugs. The reserve power of the heart in children is almost 
always to be relied upon except in malignant sepsis, and time and again 
drugs have received the undeserved credit of having sustained the patient 
in critical times. 

Stimulation, alcoholic or non-alcoholic, is contraindicated when the 
pulse is full and strong, and it may be injurious in such conditions. How- 
ever, when the pulse becomes weak and compressible, and long before it 
becomes intermittent, stimulation is necessary. 

Apparatus for Infusion and Hypodermoclysis. — A good infusion apparatus 
should possess the following qualities: It should be cleanly, convenient, 
easily kept in order, and capable of being immersed in warm water in order 
to maintain the temperature of the contained infusion fluid as equable as 
possible. The temperature of the infusion fluid as it reaches the cannula 
should be known. Finally, the apparatus should be adapted for use in 
intracellular infusion. In the apparatus herewith figured the bottle is 
graduated in ounces. Through the rubber cork, which is secured by a simple 
clamp and screw device, two lengths of glass tubing are placed (A, B), 
the one reaching to the bottom of the bottle, the other terminating just 
within the bottle; in the course of the latter a bulb is blown in which a 



Whiskey, . . . 
Tokay wine, 
Champagne, 



5j to Sviij; 
5j to 1 pint; 
Sij to 1 quart 



Acid benzoic, J 
q. 4. h. in sweetmeats or sweet chocolate. 




gr. j to iij. 



GENERAL SYMPTOMATIC MANAGEMENT 



73 



mass of cotton or lamb's wool is placed as an air filter. To the glass tube 
a rubber bulb is attached. To the long tube a length of rubber tubing is 
connected, and to the farther extremity is attached a piece of glass tubing 
in the interior of which a ther- 



mometer is placed. Finally, a 
conveniently curved metal can- 
nula is connected with the latter 
by a short piece of rubber 
tubing. 

The manner of emptying the 
apparatus is as follows: The 
bottle is filled with decinormal 
saline solution of the proper 
temperature. Hot water is 
added to that in the basin from 
time to time, as required to 
maintain the temperature with- 
in the bottle. The infusion 
fluid is forced from the bottle 




by Slow and steady strokes of FlG , 2 6.— Apparatus for Venous Infusion. 
the bulb, air being driven above (Dr. Fowler.) 

the surface of the water, pass- 
ing through the filter on its way to the bottle. As much or as little 
pressure as may be desired may be made in this way, this being graduated 
according to requirements. 



GENERAL SYMPTOMATIC MANAGEMENT 

DYSPEPTIC SYMPTOMS AND THIRST 

Coated Tongue, Nausea, Vomiting, Diarrhoea and Belching of Gas. — 

In acute and chronic illness digestion is always impaired and dyspeptic 
symptoms are complained of. After the bowels have been emptied with an 
enema or laxative drug, feeding the patient should not be pushed much be- 
yond the limits of a natural desire for food. A few drops of dilute hydro- 
chloric acid and frequent small quantities of cooled aerated water or iced 
black or peppermint tea will usually overcome nausea and vomiting, par- 
ticularly if the patient remains quiet in bed. In the presence of a coated 
tongue and foul stomach, it may be wise to get the patient to swallow a 
pint of warm water and to encourage emesis, and thus empty the stomach. 
In cases of obstinate vomiting, drop doses of tincture of iodine in sweetened 
peppermint water may be given every hour, and ice may be applied to 
the lower part of the spine. The vomiting and diarrhoea of acute gastro- 
enteritis in adults generally subside after a few doses of the following 
medicine: 

T) Morphin. sulphat., gr. \; 

Tinct. Valerianae athereae, o ij - 

Signa: 5 to 30 drops in cooled carbonated water or on cracked ice every 
hour until relieved. 



74 



GENERAL SYMPTOMATIC MANAGEMENT 



Morphine should be given to children only in very exceptional cases. 
Incessant vomiting is encountered in bowel obstruction, in cerebral cases, 
in virulent septicaemia from various causes, and in intense intestinal putre- 
faction from obstinate constipation. Stomach washing with a tube is 
occasionally necessary to overcome this symptom. Thirst may be relieved 
by giving cooled carbonated or farinaceous water, or cracked ice and water, 
and iced tea. In some cases the sipping of warm water, or the sucking of 
a raw prune, will relieve thirst. To prevent drying of the mouth a moist- 
ened piece of plain gauze may be applied over the lips, and the mouth 
should be frequently rinsed and a few drops of salt water poured into the 
nostrils occasionally. 

LAXATIVES IN ACUTE ILLNESS 

It is hardly ever a mistake to begin the treatment of a case of acute 
illness by first emptying the bowels. This can be accomplished in children 
and adults by a soap suds enema from 4 oz. to 2 quarts, or by the administra- 
tion of drugs. Children should have from two to five grains of calomel, 
to be followed by a saline, or may take a wineglassful of citrate of magnesia 
or half a teaspoonful of rhubarb and magnesia or maltine with cascara or 
a tablespoonful of castor oil. Powdered castor oil is now in the market 
under the name of Ricinus Siccol. It is tasteless and contains 50 per cent 
of oil and may be given in milk without the patient knowing it. 

It is a weak preparation at best. 

Adults may take Hunyadi, apenta or Rubinat waters, tamar indien, 
infusion of senna with sodium sulphate, 

or Podophyllin, gr. \ to ^, ~] 

Calomel, gr. 5 to 10, >pro dosi; 

Pulv. aromat., gr. iij, J 

or compound licorice powder,. . 3j to 3ij, pro dosi. 

Laxatives for chronic constipation are discussed in the chapter on Con- 
stipation. 

DIAPHORETICS AND DIURETICS 

Diaphoretics. — Elimination by the action of the skin and kidneys is 
often accomplished by means of so called diaphoretics and diuretics. To 
induce sweating we employ in adults and children the hot bath, hot pack, 
and hot drinks, such as peppermint, chamomile, catnip tea, and hot lem- 
onade. The most powerful diaphoretic drug is pilocarpine (jaborandi), 
which may be given in X V to \ grain doses to children and adults every 
two to three hours until the desired effect is produced. The dose of infusion 
of jaborandi is 2 to 3 drachms. Owing to its heart depressing effects, it 
is not an absolutely safe drug in septic fevers with a dry skin, and it is 
therefore not employed to any great extent by careful physicians who 
are anxious not to do harm. In collapse from pilocarpine there is usually 
a cold perspiration, with a fine rapid and intermittent pulse, and in extreme 
cases profuse salivation and pulmonary oedema. It may be well to remem- 
ber that pilocarpine and atropine are antagonistic. When the stomach 



EXPECTORANTS AND COUGH MIXTURES 



75 



is not rebellious, the following diaphoretic powder may be taken with a 
hot drink at bedtime: 



M. sig., one dose. 

Diuretics and their Doses. — Drugs which increase arterial pressure or 
salts which are readily diffusible and combine with water are useful as 
diuretics. The following drugs may be used singly or in combination: 

Infusion of digitalis, in 3j doses for children; in 5iv doses for adults, 
about every three hours. 

Tincture of digitalis, gtts. 5 to 30, four times a day. 

Fluid extract of digitalis, gtts. 1 to 5, also subcutaneously, in urgent 
cases. Watch for a cumulative effect and the digitalis pulse. 

Tincture of Strophanthus. — Rapid action; no cumulative effect; dose, 
gtts. 5, four times a day. Also in tablet form as strophanthine, dose, 
to sh gr- 

Squill. — Fluid extract; dose, gtt. 1 to 3. 

Caffeine, Sodium Benzoate. — Readily soluble in water; dose, gr. 1 to 5 
for adults, gr. 1 to 2 for children. Also subcutaneously. 

Theobromine Sodium Salicylate (Diitretin). — Readily soluble in water. 
Should be employed when digitalis and caffeine are used without success. 
The dose is gr. x to xv four to six times a day. The diuretic action 
should be noticeable within one to three days. 

Camphor. — Gr. 1 to 3 for adults; \ to 1 for children, with sugar or 
chocolate. In oil (1 to 15), subcutaneously. Also in combination with 
digitalis and benzoic acid. 

Calomel or Blue Mass. — Gr. 5 to 10, twice a day for two days. May 
be given in combination with jalap. 

Acetate of Potassium. — Soluble in water. Dose, 10 to 60 gr. three times 
a day. When diuresis is to be stimulated, it is often a good plan to begin 
with calomel or blue mass and follow up its effects by the administration 
of other diuretics of the foregoing list, together with hot drinks. When 
patients do not urinate, we must not fail to examine the bladder for a 
possible retention of urine. 



A cough is an expulsive effort at expectoration, and unless extremely 
harassing should not occasion alarm. When a cough takes its origin in 
the nasopharynx, the nasopharyngeal toilet (salt water and albolene spray) 
is indicated, or local cauterization with a 2 per cent solution of nitrate of 
silver. To allay reflex irritability and check cough, opium and its prepara- 
tions may be given, with or without expectorants. Expectorants are 
occasionally necessary to aid nature in expelling secretions, particularly 
in feeble children and very old people. 

Ipecac, ammonia, benzoic acid, camphor, and iodide of potassium are 
examples of expectorants. Free expectoration is more readily obtained 
when the patient receives plenty of water. 



Iy Pulv. doveri, . . 
Camphorse, . . . 
Pulv. chocolad. 



gr.5-10; 

gr- l-i; 

gr. 20. 



EXPECTORANTS AND COUGH MIXTURES 



76 



GENERAL SYMPTOMATIC MANAGEMENT 



The writer makes use of the. folio wing formulae in his practice: 

Py Tinct. opii camphoratse, 3ij- 

Signa: 5 to 15 drops in sugar water once or twice at night to check 
cough in a child. 

Py Tinct. opii camphoratse, 1 _ _ 
Vini. ipecacuanhas, J ' 

Dose, 10 to 15 drops. Sedative and expectorant for a child. 

fy Liq. ammon. anisati., 3ij- 

One-half to 5 drops in sugar water several times a day for children and 
adults. Expectorant. 

Py Ammon. chlorid., 3j; 

Morphin. hydrochloride, gr. \ ; 

Aquae, ) __ „ . 

c ■ .... > aa, 51- 

byrupi pruni Virginian, j 

Dose, a teaspoonful every three hours for adults, to check cough. 

Py Potassii iodidi, 3ij ; 

Tinct. opii camphorat., 3ij ; 

Liq. ammon. anisat., 3ss. ; 

Syrupi Tolutani, 5ij ; 

Aquae, ad., §jv. 

Dose, £ teaspoonful to one tablespoonful three to four times a day. An 
expectorant for children and adults. 1 

Sedatives for adults. 

R. Codeine, gr. \ to gr. \]A 

Morphine, gr. \ to gr. \, Vpro dosi. 

Heroin, gr. tV, i 

May be given in powder or tablet form in solution with syrup of Tolu 
or mucilage, or subcutaneously. 

Camphorae tritae, gr. j, 

Acid, benzoic, gr. iij, Vpro dosi. 

Extracti hyoscyami, gr- i, j 

In water or capsule or in powder form, to be taken in sweetmeats three 
times a day as an expectorant for adults. 

Terebene and terebene hydrate may be taken internally for any form of 
chronic bronchitis. As an expectorant the dose is from 4 to 20 drops in 
syrup or on sugar, also in combination with heroin, and it may be admin- 
istered by inhalation in all throat affections (2 oz. in a week). Sedative 
and expectorant troches are sold in the shops ready made. They are 
useful in slight ailments. Black Forest pine needle troches, Ems pastilles, 
and red gum lozenges are useful to allay cough. 



1 Ether is a powerful expectorant in subacute and chronic bronchitis. Adults may 
take 5 to 10 drops on sugar several times a day. Children may take 1 to 2 drops. 



DYSPNCEA 



77 




INHALATIONS 

The various saline antiseptic and balsamic inhalants in the shape of 
vapors and sprays are of little value as compared with the soothing effects 
of breathing and living in the pure, fresh, dust free air of the mountains 
or the seashore. Inhalation therapy is quite popular among the laity and 
is a routine method of treatment in sanatoria. 1 In private practice, in 
cases in which a moist atmosphere would favor expectoration, the humid- 
ity of the air of the sick room may be increased by evaporating water 
from an open vessel or croup kettle over a flame, and to the water may 
be added oil of turpentine, oil of eu- 
calyptus, compound tincture of benzoin, 
terebene, creosote, etc. 

The upper respiratory tract may be 
lubricated by means of an inexpensive 
hand atomizer containing benzoinated 
albolene, etc. 

Adults may directly inhale hot med- 
icated moist air by sprinkling the sub- 
stance to be inhaled upon several layers 
of flannel wrung out of hot water and 
held directly over the face. Oxygen 
inhalations are employed in a routine 

manner — the author has never observed any marked beneficial effects from 
oxygen inhalations in hospital or private practice. Inhalations of ozone, 
iodide of ethyl, amyl nitrite, and chloroform are occasionally employed on 
special indications — also the vapors of stramonium and nitre and in the 
form of cigarettes. 

DYSPNCEA 

This is a very distressing symptom, and a careful study and determina- 
tion of its immediate and remote causes will aid in suggesting the means of 
affording relief. An embarrassed heart or lung may require venesection 
or drug stimulation; general oedema, ascites, or hydrothorax may necessi- 
tate in addition scarification and puncture and subsequently morphine 
or chloral at night to secure rest. A dyspeptic and neurotic dyspnoea will 
often pass off after we have given the patient 10 to 20 drops of compound 
spirit of ether on sugar. The dyspnoea of arteriosclerosis and Bright's 
disease usually demands morphine subcutaneously administered. 2 Dys- 
pnceic patients breathe easier in an upright position; thus in severe cases 
the patient may sleep in a Morris chair or in bed in an upright and forward 
posture, the arms and head resting on a benchlike support. 



Fig. 27. — Atomizer for Albolene. 



1 From experiments made to show the behavior of atomized fluids in the respiratory tract 
it has been shown that a considerable portion of the inhaled cloud condenses on the pos- 
terior pharyngeal wall, and that the quantities reaching the deeper parts are too minute to 
have any therapeutic value. 

2 Neurosis of the phrenic nerve with diaphragmatic inactivity or spasm has been 
observed as a cause of dyspnoea. 



78 



GENERAL SYMPTOMATIC MANAGEMENT 



PAIN IN ACUTE AND CHRONIC ILLNESS 

Pain, if severe, should be relieved; sometimes change of position or 
the application of a cold compress or hot water bag or mustard plaster 
will relieve pain. Pain, if localized and severe, is best overcome by means 
of a hypodermic injection of morphine, gr. J to ^, as in rheumatic arthri- 
tis or intestinal or biliary colic, or after injury. Pelvic and rectal pain 
may often be relieved by a suppository of 

Extr. opii, ) __ o-r 1 • 

Extr. belladonna;, ) aa ' S ' *' 
Butyr. cacao, gr. 10 ; 

to be applied per rectum or vaginam. In severe enterocolitis in chil- 
dren a suppository of these drugs in T V of the dose mentioned is often of 
great value. 

Neuralgic pain may necessitate a hypodermic injection directly over 
the seat of the pain. Frequently a dose of bromide of potassium or chloral 
hydrate, by inducing a restful sleep, will overcome pain. Neurotic in- 
dividuals should not be encouraged in the use of opium and anodynes 
for moderate pain. 

NERVOUSNESS AND INSOMNIA IN THE ABSENCE OF PAIN 

These are very distressing symptoms. A warm bath, a cooling sponge 
bath, an ice cap, and, in adults and older children, the quiet assurance that 
all will be well, may quiet a patient. The following drugs are occasionally 
of great service: Codeine, by the mouth, gr. \ to ij for adults, -gV to yV for 
children. 

3 Codein -> gr.jtoij,) dogi 

Urethane, gr. 30, ) 

To be taken at bedtime (for adults). 



Hydrate of chloral, 
Potass, bromide, 

Dose for an adult. 



aa, gr. 15 to 30. 



Or hydrate of chloral and potass, bromide, aa, gr. 1 to 2, for a child, 
in sweetened water or per rectum. 

Or trional or sulphonal in 15 gr. doses in milk, for adults. 

In cerebral unrest hyoscine (Merck) is indicated. Dose for the insane, 
gr. -jV; for the sane, gr. y^g- (may be repeated). In insomnia with 
pain or severe dyspnoea a hypodermic injection of morphine is often neces- 
sary. If the insomnia and dyspnoea are due to massive pleuritic effusion 
or ascites, the liquid must be removed; if to pulmonary congestion, a vene- 
section should be done. The writer has been disappointed in lactucarium 
and hasheesh as dispensed in our country. Beer or porter at bedtime may 
induce a quiet sleep. 

Counterirritants and indifferent external applications have no scientific 
or precise indication. The writer makes use of the ice bag, hot water 



VENESECTION AND LOCAL DEPLETION 



79 



bag, and cold wet compress. The latter should be used in connection with 
rubber sheeting or oiled silk, to prevent general wetting of the bed. Poul- 
tices may be discarded as offering no advantage over the bag, and the 
physician need not support superstitious ideas by speaking of pneumonia 
jackets, etc. 

As counterirritants, dry cupping, mustard baths, mustard plasters, can- 
tharides plasters, and iodine preparations are useful. Soothing external 
applications and percutaneous therapeutics are discussed in the dermato- 
logical memoranda and other special chapters in this book. 

VENESECTION AND LOCAL DEPLETION 

In cardiac and respiratory embarrassment, when compression of the 
arm below the shoulder produces marked distention of the veins below 
(forearm and elbow), and when heart drugs fail to stimulate the lagging 




Fig. 28. — Technique of Venesection. 



heart muscle, the unloading of the heart or embarrassed circulation by 
venesection is indicated. Six to fifteen ounces of blood may be withdrawn. 

Local depletion by means of scarification and puncture, wet cupping, 
or leeching is performed in ophthalmic and aural practice for the relief of 
local hypersemia or congestion. Leeches will readily attach themselves 
if the parts are washed in ice cold water and then slightly scarified as for 
vaccination. After the leech drops off, the bleeding point will continue, to 
bleed if hot cloths are applied. In case of too profuse haemorrhage, ice 
cloths and compression may be used. Scarification is sometimes employed 
in lymphangeitis and erysipelas, followed by a wet antiseptic dressing. 



80 



GENERAL SYMPTOMATIC MANAGEMENT 



Venesection in Children. — This may be indicated in respiratory failure 
and for the purpose of relieving an embarrassed heart in 



Bronchitis, 

Pneumonia, 

Cardiac lesions, 

Convulsions due to congestion of brain 
and in ursemic conditions, 



Cyanosis 

and 
Dyspnoea. 



From one to three ounces of blood may be removed. Venesection in 
children is not often practised. 

The Technique of Venesection. — The arm is constricted between the 
shoulder and elbow by means of a silk handkerchief. The region of the 




Fig. 29. — Dry Cupping. 



bulging median vein is cleansed and made anaesthetic by injecting a 2 per 
cent cocaine or stovaine solution. After incising the skin the vein is 
punctured. A firm bichloride compress will stop the bleeding. 

THE NASOPHARYNGEAL TOILET 

The nasopharyngeal toilet, as advised by the author in all febrile diseases, 
consists in the instillation into each nostril, by means of an ordinary tea- 
spoon, of a spoonful of weak salt water morning and evening (at bedtime 
and on rising) as the children lie on their backs with the nose tilted up and 
the mouth open. The liquid does not wash through at once; some of it 
remains in the various recesses of the nasal cavity and is eventually sneezed 



THE NASOPHARYNGEAL TOILET 



81 



out or swallowed. In this way putrescible matter and bacteria are washed 
away. 

This form of mechanical antisepsis is indicated as follows: It is the 
best method of local treatment of all cases of diphtheria, in which instances 
it should be resorted to every two hours; moreover, it is the most satisfac- 




Fig. 30. — Nasopharyngeal Toilet (Author's Method). 



tory local routine treatment in all diseases in which diphtheria frequently 
sets in as a complication, e. g., in measles, scarlatina, and pertussis; fur- 
thermore, it is a necessity before and after amygdalotomy and all operations 
on the nose and throat. This method is far superior to gargling, and the 
writer, after an experience of more than fifteen years with this method, 
again takes pleasure in recommending it on account of its great value and 
harmlessness. In many forms of reflex cough, also in pneumonia and 
tuberculosis, it is far superior to nauseating expectorant mixtures, and in 
all forms of febrile disease in which the nasal secretion becomes dry, crusty, 




Fig. 31. — Blunt Nasal Irrigation Syringe. 



or hardened, half a teaspoonful of salt water instilled into each nostril 
affords much relief. The nasopharyngeal toilet not only does not provoke 
middle ear and sinus complications, but apparently prevents them. If 
chemical antisepsis is in addition urgently demanded, as in malignant sore 
7 



82 



GENERAL SYMPTOMATIC MANAGEMENT 



throat, we may employ a 5 per cent solution of ichthyol in water or a 
bichloride of mercury spray, 1-10,000. The surface of the nose may be 
covered with vaseline, and an albolene spray may be used to advantage 
in some cases when the watery fluid is not soothing enough. See also 
article on Diphtheria in Pediatric Section. 



TONICS IN THE CONVALESCENT STAGE 

The best general tonic after acute illness is probably a change of air, 
from the city to the country, from the mountains to the seashore, and 
vice versa. A regulated digestion and exercise, massage, baths, and restful 
surroundings are welcome to every convalescent. The administration of 
dilute hydrochloric acid after meals will aid digestion, and a normal diges- 
tion and good food will soon bring the blood composition up to the proper 
standard. 

Hydrochloric Acid. — 

Py Acidi hydrochlor. dil., 5jv. 

Five to ten drops in sugar water after eating. 

Py. Acidi hydrochlor. dil., ) __ 
Tinct. nucis vomic, ) ' 

Five to ten drops in sugar water after eating. 

Acidi hydrochlor. dil., 5j; 

Ess. pepsini, §ij. 

A teaspoonful in water after eating. 



I 



Py Acidi hydrochlor. dil., 
Tinct. gentian, comp., 
Tinct. rhei vinos., 
Tinct. cinchonse composit.,1 
Half a teaspoonful in water after eating. 



aa, 3jv. 



Py Acidi hydrochlor. dil., 
Tinct. quassia?, 



aa, oj; 



Ess. pepsini, q. s. ad., giij. 

A teaspoonful in water after eating. 

Py Acidi hydrochlor. dil., 5j; 

Bismuthi subnit., 3j; 

Ess. pepsini, gjv. 

A teaspoonful in water after eating. Shake well. 



If iron, arsenic, phosphorus, and other drug tonics are to be given, the 
tongue must first be clean, and should a clean tongue become coated after 
the administration of drug tonics, the latter should be discontinued and 



MENTAL THERAPEUTICS AND WORK FOR THE SICK 



83 



hydrochloric acid substituted. The author uses the following formulae 
in his practice for anaemic convalescents: 

Tinct. ferri. chlorid., in doses of 2 to 20 drops three times a day. 
Tinct. ferri. pomati, 5 to 20 drops three times a day. 



Dose, J to 1 teaspoonful three times a day. 

Liquor Peptomangan. — Dose, 5 to 15 drops three times a day. 
Liq. Bromo Mangan. — Dose, 5i to 5j- 

Elixir Calisaycc Cum Ferro et Strych. — Dose, 3j to 5jv several times 
a day. 

Also the glycerophosphates and hypo phosphites of iron and iron tropon. 

Arsenic is best administered in the shape of Fowler's solution, 1 to 5 
drops in water three times a day after eating. 

Phosphorus in the shape of Thompson's solution may be given to chil- 
dren in 10 to 20 drop doses three times a day in water. Elixir of phosphorus 
is a palatable preparation. Phosphorus chocolate lozenges may be given 
to children as candy. Adults take larger quantities. 

A very good alcoholic malt tonic for convalescents is barley wine, and 
several of the large brewing companies of our country make a palatable 
malt beverage containing little or no alcohol. 

Malt and maltine preparations are beneficial for convalescents. 

MENTAL THERAPEUTICS AND WORK FOR THE SICK 

The influence which may be exerted on the minds of the patients is of 
the utmost importance in acute as well as in chronic ailments. Abnormal 
mental conditions lead to an exaggeration of symptoms, to imaginary ail- 
ments, and to undue apprehension, which interfere (by a general depressing 
effect upon bodily functions) with the favorable progress of disease. De- 
termination and a strong will are efficacious in resisting and overcoming 
disease. Lives are made miserable by injudicious injunctions to rest from 
work or by failing to suggest some congenial work. Old people who are 
apt to become introspective and a burden to themselves are often made 
happier if they go back to nature and spend their declining years in the 
country, where they can always find some form of pleasant occupation 
during the day and rest and quiet surroundings at night. In chronic 
ailments the tactful physician will hold out to the patient the encouraging 
features of a case, and not "imitate a judicial sentence of death " by telling 
the patient that he is in no immediate danger and that he may live for 
several weeks or months. A hopeful attitude toward the patient is 
always correct and ethical. It prolongs life and alleviates suffering. 

In conclusion, I wish to emphasize that the important points in the 
management of acute febrile disease are diet, hydrotherapy , rational stimu- 
lation, and free breathing of pure cool air. Drugs no longer dominate our 
therapeutics. After the bowels have been made to move, drugs are not 
indicated, unless for some special and substantial reason. The more in- 



Elixir gentianae comp., 
Tinct. ferri. chlorid., . 



oij; 
3j. 



84 



GENERAL SYMPTOMATIC MANAGEMENT 



telligent part of the community have lost faith in drugging, and medical 
men should not continue to countenance or encourage superstition as to 




Fig. 32. — Infection and Sloughing of the Skin from Unclean Hypodermatic 

Injections. 



drugs. When a placebo seems indicated, a few drops of hydrochloric acid 
in sugar water or in essence of pepsin are rational and will do no harm. 
Infants do not require a placebo, and young and inexperienced mothers 
should be gently but firmly enlightened on such matters. Drugs may be 
administered by the stomach, by the rectum, by inunction, or by hypo- 
dermic injection, with reference to the local or general therapeutic activity 
sought. 

Dose Determination. — Regarding dose determination, it is well to re- 
member the rule advanced by Dr. V. C. Pedersen, of New York: A full 




Fig. 33. — Bed Grapple for the Comfort of Patients. 
(From the Medical Council, 1904.) 



therapeutic dose will be tolerated by a subject twenty years of age and 
upwards; the proportionate dose for any age, twenty years or less, is found 




Fig. 35. — Feely Invalid Bed, 



86 



GENERAL SYMPTOMATIC MANAGEMENT 



by taking of the full dose and multiplying the result by the age in 
years or fractions of years. 

The Metric System in Prescription Writing has made but little progress 
in the United States. 

To facilitate the conversion of apothecary's weights and measures into 
the metric system the following tables and rules are not too cumbersome 
and tedious for practical use: 

To convert ounces into grammes, multiply by 30. 

To convert grammes into ounces, divide by 30. 

To convert troy grains into centigrammes, multiply by 6. 

To convert centigrammes into troy grains, divide by 6. 

To convert troy grains into milligrammes, multiply by 60. 

To convert milligrammes into troy grains, divide by 60. 

To convert troy grains into grammes, or minims into fluid grammes, 
divide by 15. 

To convert grammes into grains, or fluid grammes into minims, multiply 
by 15. 

To convert drachms into grammes, or fluid drachms into fluid grammes, 
multiply by 4. 

To convert grammes into drachms, or fluid grammes into fluid drachms, 
divide by 4. 

PRACTICAL APPROXIMATE GRAMME VALUES 



Grammes 



0.004 

0.005 

. 006 

0.008 

0.010 

0.015 

0.02 

0.03 

0.05 

0.06 

0.12 

0.20 



Grains 



10 



15 
18' 



Grammes 



0.26 
0.30 



0.52 
0^60 ' 



1.00 

i!2o 



Grains 



20 (3j) 
24 

30 ( 3 ss) 



36 

40(3ij) 



60( 3 j) 



90 



Grammes 



1.3 

1.5 
2.0 



2.3 
2.6 



4.0 



6.0 



Grains 

100 

120 
150 
180 
240 
300 
360 
420 
480 



3i] 



Invalid Bed. — In severe or protracted illness a properly constructed 
invalid bed or bed grapple is a great convenience for patient and nurse. 
(See Illustrations.) 



CHAPTER III 



PEDIATRICS 

Synopsis: Care of the New-Born. — Diseases of the New-Born. — Deformities. — Malforma- 
tions. — Infant Feeding. — Facts about Milk. — Maternal Nursing. — Cow's Milk for In- 
fant Feeding. — Diet for Children after Weaning. — Ailments of the Mouth in Infants 
and Children. — Mumps. — Indigestion and Diarrhoeal Disorders. — Malnutrition. — 
Rickets. — Marasmus. — Scurvy. — Worms in Children. — Tuberculous Peritonitis in 
Children. — Diseases of the Respiratory Tract in Children. — Colds, Bronchitis, Pneumo- 
nia, Pleurisy, Empyema, Whooping Cough. — Pyothorax. — Thymus Gland. — Bronchial 
Lymph Nodes. — The Nasopharynx. — Diphtheria and Croup. — Intubation and Tra- 
cheotomy. — The Nasopharyngeal Toilet. — Tonsillitis. — Peritonsillitis. — Quinsy. — En- 
larged Tonsils. — Adenoid Growths. — Retropharyngeal Lymphadenitis and Abscess. 
— Eruptive and Other Fevers in Children. — Measles, Rubeola, Scarlet Fever, Malaria, 
Typhoid Fever. — Glandular Fever. — Vulvovaginitis and Masturbation. — Familiar 
Forms of Nervous Derangements Peculiar to Early Life. 

INTRODUCTORY REMARKS 

In this section the author presents in a clinical garb the diseases which 
are peculiar to early life or show marked peculiarities in infancy or child- 
hood. In order to avoid unnecessary repetition, no attempt has been made 
to enumerate and discuss all diseases occurring in children, and when an 
apparent omission is noticed, particularly as regards skin lesions, urogenital 
and circulatory disturbances, etc., which present no marked difference in 
childhood, the reader will find the matter discussed elsewhere. 

CARE OF THE NEW-BORN 

The Cord. — Express the excess of gelatine from the cord, dust with 
subnitrate of bismuth, and wrap in aseptic gauze or absorbent cotton, 
after which the flannel binder around the abdomen may be applied. The 
dressing is not to be unnecessarily disturbed, and may be removed at the 
time the cord separates from the body, about the fifth or seventh day. The 
stump may then be dusted with mild aseptic powder and a small pad 
placed in situ. The cord stump is practically healed about the tenth day. 

Asphyxia. — This condition when present will call for prompt relief. 
The infant is cyanotic, livid, or frequently, when the asphyxia is deep, 
the child presents a pale, deathlike appearance. This condition is due to 
many and various causes, prominent among which are inherent weakness 
of the child, pressure of the cord about the neck, prolonged labor, undue 
pressure exerted on the head by forceps, aspiration of mucus, blood, or 

87 



88 



PEDIATRICS 



amniotic fluid, or illness of the mother (convulsions during labor, anaesthesia, 
etc.). In attempting to reestablish the respiration, there are many methods 
of resort. First, clear the mouth and pharynx with a swab of cotton to 
disengage accumulated mucus. If mucus or fluid obstructs the trachea, 
aspiration by the rubber catheter is indicated. Applications of alternate 
hot and cold water and spanking are mechanical means of favoring better 
respiratory efforts and assisting the flagging circulation. Mouth to mouth 
inflation, with the infant's head thrown back, may be tried. Sylvester's 
and Schultze's methods of inducing artificial respiration are commendable, 
also, rhythmical traction of the tongue. After the reestablishment of 
respiration, the infant should be observed for some hours, and one or more 
of the combined methods above indicated resorted to in instances demand- 
ing repetition. Asphyxia may result in cerebral congestion, effusion, 
thrombosis, extravasation, and destruction of nerve tissue with secondary 
inflammation and cystic degeneration. Prolonged asphyxia of the new- 
born may result in idiocy; about 40 per cent of the idiots who were first 
born children have a history of asphyxia. The longer the duration of 
asphyxia, the greater the danger. The immediate treatment of asphyxia 
is therefore very important. 

Mouth. — The maintenance of cleanliness of the mouth is important. 
It may be wiped out with soft lint or cotton moistened with 2 per cent 
boric acid solution, but we must avoid washing out the mouth directly after 
a nursing, to prevent vomiting of recently ingested milk. The mouth of 
infants is exquisitely tender, and cleansing with the finger, unless carefully 
done, is apt to injure the epithelial surface and result in ulceration. The 
same injury occasionally results from the pressure of too large a rubber 
nipple. Ulcerative stomatitis in the new-born is observed over the ham- 
ular process of the sphenoid, and is due to irritation in cleansing the mouth 
or may be due to the irritation of epithelial pearls in the roof of the mouth. 
It shows as a superficial ulcer, covered with a yellow film and bounded 
by a red line, and may occupy the larger part of the soft palate. Such 
a child appears in good health and has no fever. The epithelial pearls 
are a physiological formation and require no treatment, as they disappear 
in time. The stomatitis yields to the usual local antiseptic treatment. 

The Eyes. — Avoid the use of a sponge to the eyes. Fresh tufts of ab- 
sorbent cotton are cleanlier and less irritating. To prevent the occurrence 
of ophthalmia neonatorum, instil a £ to 2 per cent nitrate of silver 
solution into the eye and neutralize after a few minutes with mild sodium 
chloride solution (table salt). 

The Temperature at birth is about 100° F. This soon falls, and varies 
from a fraction to a degree under the action of the bath, clothing, and 
skin radiation. The average rectal temperature of the healthy infant is 
about 99°. 

Respiration in infants is diaphragmatic, and the rhythm is easily dis- 
turbed. At birth we observe 35 to 40 respirations a minute. 

Pulse. — At birth it is quite rapid, more so in the female than in the male 
infant. In infancy, too, the slightest disturbance in activity from rest to 
motion profoundly influences the pulse rate and its force. The average 
frequency of the pulse is about 120 to 150. 



POINTS TO BE OBSERVED BY NURSES 



89 



Weight. — At birth it varies, the average weight being about seven 
pounds. During the first few days after birth there is a slight loss in weight 
and then a gain of about half an ounce daily. The average gain in weight 
for the first two years is about 20 pounds, in length about 10 inches. 

The Stools. — The color of the first stool (meconium) is black. Normal 
stools are yellow and like mush. Curdy and green stools and loose 
watery stools indicate some form of indigestion. 

Clothing. — The clothing should be of such texture and structure as 
to insure everything that the terms comfort and hygiene comprehend. 
Avoid the use of tight and constricting bands at the waist. The flannel 
band should be about four inches wide, without hem, and applied smoothly 
twice around the body. For diapers soft cotton napkins one yard by one 
half yard, folded once, are suitable. Rubber outer diapers have their 
advantages for purposes of cleanliness, but should be worn only on occa- 
sions of outing, when the conditions are such that fresh diapers cannot be 
applied. 

The stockings should be secured to the diapers. The outer garments 
of the infant should not be too long and they should open in front. 

The Nursery. — Children will not thrive unless they have sunlight and 
unless they sleep in a well ventilated room. During the day the room should 
have a temperature of 68° to 70° F., at night 60°. Under no circumstances 
is a gas stove or oil stove to be used to heat a room unless it is connected 
with a flue so that the products of combustion may escape. The amount 
of air space necessary for a child is from 800 to 1,000 cubic feet, with proper 
facilities for ventilation. The child, after three weeks have elapsed, is to be 
taken out of doors daily in clement weather, to enjoy the beneficial effects 
that sunlight and fresh air conduce to. At the sixth month the baby is 
to be vaccinated. Babies attempt to sit up about the sixteenth week and 
try to stand about the ninth or tenth month. The first milk teeth come 
about the seventh month, and the permanent teeth about the seventh year. 

Nursery Requisites. — Bath tub; rice powder and pepperbox; wash 
cloths (no sponges) ; alcohol lamp for warming purposes ; hot water bag ; 
fountain or piston syringe with soft rectal tube; absorbent cotton for the 
eyes; fennel tea; white vaseline. 

Bathing Infants. — A daily bath should be given at about 95° to 99° F. 
in a warm room. As children grow to one year, the bath water may have 
a temperature of 90° — for older children 70°. During warm weather one 
bath night and morning is necessary, or one warm bath and a cool sponge. 
The bath should be of short duration, followed by mild friction when the 
child is out of the water. 

POINTS TO BE OBSERVED BY NURSES 

Regular Habits must be established by feeding at regular intervals and 
by putting the child to sleep at the same time of the day or evening. 

Wakefulness is principally caused by overfeeding, night-feeding, thirst, 
or constipation. 

Napkins, not properly washed and dried, will hold urinary salts and 
produce excoriations. In handling a baby the head and neck must be sup- 



90 



PEDIATRICS 



ported, and in feeding a child from the bottle an overflow of milk must be 
avoided by feeding in a semirecumbent posture and by careful watching. 

Salt water (a teaspoonful to a pint) is useful for the purpose of keeping 
the nose clean and moist. A few drops may be put into each nostril by 
means of a blunt spoon. 

Premature Infants. — Prognosis : Few infants born before the twenty- 
ninth week are saved. Continued loss of weight is discouraging, and the 
sooner a steady gain in weight is recorded the better. 

Treatment. — Premature children require great care and attention, 
and if too feeble to take the breast can receive the mother's milk removed 
with the breast pump from a spoon, or pipette, or by means of the breast 
bottle. Regular and proper feeding, preservation of the bodily heat, and 
great attention to cleanliness must be observed. Simple prematurity is 
oftentimes accentuated by constitutional debility of the child, owing to 
cachexia of the mother from tuberculosis, syphilis, carcinoma, malaria, 



Bright 's disease, and other acute diseases, such as typhoid fever and 
pneumonia, or persistent vomiting. If premature children are to thrive in 
an incubator, this apparatus must be connected with the outer or fresh air; 
and they must have incessant care and attention. According to the 
writer's experience premature infants can be raised and do better with- 
out an incubator, if kept in a room at about 80° F., their heat sustained 
by wrapping in cotton batting. 

In cases of prematurity, the mother's milk is inferior to the milk of a 
wet-nurse, whose infant must be healthy, full term, two weeks of age. Pre- 
mature infants if deprived of the breast are fed on low strength top milk 
(J) by means of a medicine dropper. They take from 5j to §j about 
every two hours and should be fed slowly (see also infant feeding). 

The mother's breasts in the mean time should be pumped and massaged 
so that they will not dry up. The feeding is accomplished by means of a 
pipette. Asses' milk has been successfully tried in feeding premature 
infants. 




Faulty way. 



Correct way. 



Fig. 36. — How to Hold the Baby. 
(From Health Culture.) 



PREMATURE INFANTS 



91 



When there is an attack of cyanosis in a premature infant, the child 
should be inverted in order to clear the trachea; and a few drops of diluted 
whiskey may be given. Attacks of cyanosis are not necessarily fatal. 
The bowels should be made to move. Some hardy individuals can be raised 
artificially altogether. Infants of three and a half to four pounds can be 
saved at six and a half to seven 
months. A seven months' infant 
would require one half ounce of 
modified milk every hour and a half. 

The Nipples of the Mother should 
be attended to weeks before parturi- 
tion. They are to be drawn out 
occasionally and made pliable with 
cold cream to prevent subsequent 
retraction. After nursing, the nip- 
ple should be washed with boric acid 
solution. In the event of fissured 
nipple developing, associated with 
much pain in nursing, it is wise to 
draw milk with a breast pump and 
feed the child with a spoon or 
directly from a breast bottle. The 
fissure may be cauterized with 5 per 
cent nitrate of silver solution, after 
which a mild protecting salve of 
bismuth, zinc oxide, or aristol may 
be applied. The nipples may also 
be painted several times a day with 
the white of egg. 

Pus in the Breast of the Mother; 
Mastitis; Caking. — When the breast 
becomes tender and before it is ac- 
tually in a state of inflammation, a 
supporting binder should be applied 
and a dose of salts administered. 
In the event of suppuration nursing 
must cease. Milk should be re- 
moved artificially from the breast by 
the use of a breast pump. Suppura- 
tive mastitis is a surgical condition 
and demands operative interference. 

In the new-born we meet fre- 
quently with a condition of mastitis 

usually brought about by meddlesome interference with the infant's nipple 
in attempts to squeeze out secretion. Such cases as a rule are of simple 
inflammatory type and respond in a few days to moist compress treatment. 

If inflammation of the mother's breast goes on to the formation of an 
abscess, incision is necessary. The incisions are to be made radiating 
from the areola to the breast periphery, and all pockets collectively and 




Fig. 37. 



-Incubator for 
Children. 



Premature 



92 



PEDIATRICS 



individually broken up. Sufficient and thorough drainage must be estab- 
lished with suitable drainage tubes. No region of an extensively involved 
mammary gland should be left unexplored by the finger, or the operation 
has been incompletely performed, thus necessitating a second and perhaps 
a third narcosis, additional surgical interference, with the associated depress- 
ing influences, and ultimate unsatisfactory results. The operation as 
above indicated is the only radical, rational, and correct practical method 
of satisfactorily attacking and treating the condition. Appropriate sterile 
dressing should be applied over the operative area and changed alternately 
for a few days, and at each change irrigation should be practised to insure 
patency of all the tubes inserted and to keep up the desirable thorough 
drainage. With the gradual closure of the drained areas, the tubes are 
removed and the wounds treated on general surgical principles of cleanliness 
until healing is complete. 

WHEN CHILDREN BEGIN TO WALK 

The following table records experiments upon 1,220 children and gives 
the age at which they commenced to walk, and should be of interest to 
young mothers: 



Age. 


No. of Children. 


Per Cent. 


8 months 


3 



4 


2 




53 


3 




120 


9 


8 




213 


17 


5 




393 


32 


2 




520 


42 


6 




680 


55 


7 


15 months and under 


803 


65 


8 


16 months and under 


886 


72 


6 




941 


77 


1 


18 months and under 


1,048 


85 


9 


19 months and under 


1,073 


88 





20 months and under 


1,098 


90 







1,106 


90 


7 


22 months and under 


1,128 


92 


5 




1,135 


93 







1,165 


95 


5 



DISEASES OF THE NEW-BORN 

Constipation. — This is to be remedied by soap water enemata, using a 
soft rubber rectal tube for insertion or by soap suppositories. If avoidable, 
do not resort to drugs to overcome constipation. Increase the percentage 
of fat in the food and give water. Gentle massage of the abdomen once a 

day is efficacious. 

Jaundice very frequently appears in the first few days of infant life. 
As a rule it is transient, although it may persist for several weeks. Its 
presence is usually of no consequence, and frequently warm baths alone are 
efficient in dissipating the condition. When constipation is a factor, small 
quantities of Vichy water may be administered, a teaspoonful at a time. 
Infectious jaundice (Winckel's disease) is a grave condition. It is looked 



DISEASES OF THE NEW-BORN 



US 



upon as an infectious epidemic hsemoglobinuria of the new-born, with 
cyanosis and jaundice, the jaundice and nervous symptoms occurring in the 
first week of life and ending fatally in coma and convulsions in pronounced 
cases. In the absence of definite knowledge on the subject, the manage- 
ment of this symptom complex will be symptomatic. 

Colic. — The most frequent cause is overfeeding, and the majority of 
instances must be attributed to this factor. To overcome colicky attacks, 
regulate the time and quantity of feeding. As therapeutic agents, use warm 
baths, soap water enemas, warm mint tea, and rarely paregoric in five drop 
doses to counteract pain. 

Renal Colic in Infants. — Uric acid infarctions are frequent in new-born 
infants. Gravel-stone and calcareous deposits are not infrequent. Gravel 
is often found in diapers. In such cases an abundance of water should be 
supplied to the infant. 

Snuffles. — "Snuffles " in the infant is not always to be looked upon as 
syphilitic. Very frequently it is due to uncleanliness, and as a result a 
catarrhal condition is established. Treat by instilling salt water with a 
pipette into the nostrils and anoint the alae of the nose with oil or lanolin 
or vaseline to prevent excoriation and crusts. Adenoid tissue may be 
removed by scraping with the finger nail. 

Crowing Sounds and Congenital Stridor. — The majority of crowing 
sounds take their origin in the nasopharynx or larynx, and disappear when 
the children are older. A soft catheter should be passed through the nostrils 
to make sure of the absence of occlusion. Crowing sounds with and without 
stridor have been observed in cases of catarrhal laryngitis, spasm, paralysic 
and papilloma of the larynx, atelectasis of the lung, syphilitic broncho- 
stenosis, retropharyngeal abscess, adenoid vegetations, enlarged thymus 
gland, congenital deformity of the superior laryngeal aperture, etc. Oc- 
casionally there is an obstetrical laryngitis due to aspiration of septic 
material by premature respiration on the part of the child in the course of 
a slow labor. In some cases it is only manifested on exertion. 

Prognosis. — In weakly children the condition may prove fatal. As 
a rule it passes off before the end of the second year. 

Treatment. — A general tonic treatment or antisyphilitic regime is 
called for. The nasopharynx should be kept clean, and adenoids, if present, 
should be removed by scraping with the finger nail. 

Ocular Haemorrhages in the New-born. — Long and complicated labors 
naturally predispose to the occurrence of intraocular haemorrhage. Ex- 
travasations are most likely in congenitally weak children, and in those 
with a family history of haemophilia. 

Atelectasis : Respiratory failure. — Congenital atelectasis is a persistence 
of the fcetal state in any part or the whole of the lung, and is associated 
with asphyxia of the new-born; but it may occur in feeble and premature 
infants without asphyxia. Such infants show evidence of malnutrition 
and have attacks of cyanosis ending in death or recovery after repeated 
attacks. When one lung is affected, we get a difference in percussion note 
and feeble respiratory murmur, occasionally rales. 

Treatment. — The newly born should be made to cry, whether as- 
phyxiated or not, in order to promote expansion of the lungs. Artificial 



94 



PEDIATRICS 



respiration, as described under Asphyxia, and warm baths with friction 
may also be necessary. 

The Breasts of the Infant. — The breasts of the infant may swell and 
become inflamed. They sometimes contain milk, and undue handling of 
the breast or prolonged attempts to express the milk are occasionally 
responsible for infantile mastitis. When fluctuation shows pus to be present, 
an incision is indicated. 

Angeioma of the breast is occasionally observed in infants and requires 
surgical treatment. 

Excoriations and Erythema are frequently caused by the irritation of 
dirty linen, and are most frequently situated in the flexed portions of the 
limbs, the neck, the buttocks, and the perineal region. Soiled napkins 
which have been insufficiently washed contain, when dry, urinary deposits 
which act as irritants. Rice powder, starch, cold cream, zinc ointment, 
and tallow are therapeutic agents of relief. 

Pemphigus vulgaris (non-syphiliticus) is frequently observed in infants 
and runs a mild course, with but little fever, of about two to three weeks. 
The blebs contain serum which becomes turbid. It seems to be contagious 
and has a tendency to spread among children in institutions. Cleanliness 
is the best treatment. A protecting ointment of bismuth and ichthyol is 
necessary to cover the excoriated skin. Stearate of zinc powder may be 
dusted on the blebs and raw surfaces. Of course the general condition 
requires attention, and if syphilis is suspected as the underlying cause, 
specific treatment must be employed. The skin lesions of congenital 
syphilis will be discussed under Syphilis. 

General Seborrhcea Sicca (Squamosa Neonatorum) ; Ichthyosis Se- 
bacea. — The body is covered with reddish brown scales, and the skin is 
dry and shows painful fissures. If general it is usually fatal in new-born 
children. 

Treatment. — Lanolin and ichthyol, 5 per cent. Try thyreoid treat- 
ment internally. 

Congenital Ichthyosis (Grave Form). — The skin looks like furrowed 
parchment, the nostrils and ears are occluded by epithelial debris, and the 
skin feels hard and cracks or splits. The prognosis is bad. In mild forms 
life may be prolonged for years. 

Treatment. — Cleanliness, baths, inunction with pure oil. Attention 
to the bowels. Lanolin and ichthyol, 5 per cent to 10 per cent. Try 
thyreoid treatment internally. 

Sclerema and (Edema. — Both of these conditions may be congenital. 
The exact etiological factors are not definitely known, although in cedema 
a poor, weak, disturbed circulation is a factor as well as symptom. The 
treatment is to be chiefly directed toward establishing better conditions 
of nutrition and appropriate stimulation. In sclerema the skin is hard and 
indurated as opposed to the softer, non-resistant feel observed in cedema. 
A subnormal temperature is present in sclerema, and the indications there- 
fore are for the establishment of normal temperature by appropriate clothing, 
bathing, friction, and stimulation. The prognosis in sclerema is unfavor- 
able. Possibly the administration of thyreoid extract may favorably 
influence the course. 



DISEASES OF THE NEW-BORN 



05 



(Edema may be confounded with sclerema. It begins soon after birth • 
(also in premature infants), usually at the feet, and successively invades 
the whole body, particularly the extremities, the scrotum, and the labia. 
The (edematous parts are cold and pit on pressure. When the whole 
body is affected, the child's respiration is impaired, the pulse is slow, the 
temperature is subnormal, and the child is drowsy and dies. 

Prognosis. — In complete oedema this is bad; in partial oedema, fair. 

Treatment. — Hot water bags ; wrap in cotton batting; general 
massage; proper feeding (higher percentage of proteids); camphor to 
stimulate the heart; five to ten drops of camphorated oil subcutaneously 
twice daily. 

Birth Marks : Naevi, Telangiectasis, Angeioma (Superficial and Cav- 
ernous). — There are three varieties of naevi in young children — superficial 
naevi, which disappear in time and do not require treatment, and superficial 
and cavernous nsevi, which require surgical interference. Superficial naevi 
may be destroyed by the electrolytic process. The needle is connected 
by means of a needle holder with the negative pole of a galvanic battery 
and the current closed by means of a sponge electrode held in the patient's 
hand. A current of only a few milliamperes is used. The current is broken 
by removing the sponge electrode. This is the same process employed for 
the permanent destruction of hair by electrolysis. The actual cautery, 
galvanic or Paquelin, is the most satisfactory means of destroying naevi. 
The part to be destroyed is cleansed with green soap and alcohol, and 
punctured in many places with the red hot needle point. Iodoform is 
dusted on the destroyed skin and a dry scab is allowed to form and eventu- 
ally to fall off. One thorough treatment is usually all that is necessary. 
In case the vascular new growth has not been entirely destroyed by the 
cautery, a second application will be necessary. A cavernous angeioma 
is a strictly surgical affair and is best eradicated by the knife. 

Umbilicus. — The stump of the cord is frequently the portal of entrance 
of infectious disease. Tetanus and erysipelas are examples. Eczema of 
the iimbilicus is of common occurrence and responds to bismuth and zinc 
ointments. Keep the part dry and clean. Polypus, or granuloma, is re- 
moved mechanically by twisting the pedicle or by ligature or cauterization. 
Omphalitis involving the neighboring abdominal tissues may go on to 
suppuration and gangrene and spread over a considerable area. If an 
abscess forms, incision and drainage are indicated. In umbilical sepsis 
of the new-born there is usually fever and there may be purpura or petechia. 
There may be bleeding from the vagina and nose, vomiting, and muscular 
rigidity. This symptom complex is characteristic and enables us to dis- 
tinguish such cases from haemophilia. Pronounced cases are fatal. We 
must look to the future for an antitoxine for this form of sepsis, which may 
be avoided by proper management of the cord. 

Tetanus. — This is an acute specific infection. It sets in at about the 
fourth or fifth day. The portal of entrance is the stump of the cord. 
In nursing, the jaw becomes rigid and the face drawn. The body of 
the child becomes stiff and in the intervals relaxed. Fever sets in and 
death takes place from exhaustion or asphyxia. The mortality is about 
90 per cent. 



96 



PEDIATRICS 



Treatment. — Tetanus antitoxine should be administered, together 
with small doses of chloral hydrate (about half a grain) and bromide of 
potassium (about one grain), every two to three hours. Also use warm 
baths at 95° F., with mild massage and proper feeding. Obstetrical cleanli- 
ness prevents tetanus infection. 

Trismus. — Mild cases of tetanus have been termed trismus. The exact 
relation between trismus and tetanus is not known, but it is a fact that many 
cases of so called trismus get well under hygienic management and the 
administration of bromide and chloral. 

Fatty Degeneration (Buhl's Disease) is an acute fatty degeneration of 
the viscera — (heart, lungs, liver, and kidneys) — with a tendency to haemor- 
rhage, no special rise of temperature, and early death from asthenia or acute 
haemorrhage, probably due to infection. The treatment is symptomatic. 

Congenital Rigidity (Little's Disease). — A congenital rigidity of the lower 
extremities, probably due to syphilis, is known under this name and may 
necessitate symptomatic and specific management. 

Haemorrhagic Disease. — Not all cases of hemorrhagic disease are due 
to haemophilia, which is rarely manifested before the end of the first year. 
On the other hand, infants known to bleed during the first days of life 
recover and are not apt to bleed in after life. The haemorrhagic phenomena 
which are associated with various forms of umbilical sepsis are mentioned 
elsewhere. 

Umbilical Haemorrhage. — Bleeding from the cord or navel wound may 
be due to negligence in tying the cord. The writer has met with a few cases 
of severe haemorrhage from the navel cord on the third to the fifth day. A 
haemorrhagic state, or dyscrasia from congenital syphilis or from intestinal 
putrefaction and toxaemia of the mother, may be the causative factor. 

Treatment. — Apply strong alum water. Ten per cent solutions of 
antipyrine and adrenalin solution are powerful local styptics. If they 
fail to check the haemorrhage, the skin should be transfixed with needles 
and pressure exerted by means of a silk suture wound around and under- 
neath the pins. Stypticin may be given internally in half grain doses, or 
injected hypodermically, dissolved in water. A single bleeding point may 
be touched with the actual cautery. 

Gastrointestinal haemorrhage may set in at any time during the first 
week after birth. The blood comes from the stomach and bowels in smaller 
or larger quantities, usually in dark masses. It may be due to: (a) Syph- 
ilis, sepsis, haemophilia, etc.; (b) Local ulceration in the gastrointestinal tract; 
(c) Injury related or not related to labor. In most of the cases observed by 
the writer the infants appeared healthy and were of healthy parentage. 
The children usually die within one half to two days, but occasionally re- 
cover. The heart's action is generally very rapid, and finally the pulse is 
no longer felt. If the blood coagulates in the stomach, vomiting expels it. 
The prognosis is unfavorable. 

Treatment. — Careful and judicious feeding and stimulation. If 
the infant cannot suck, give the mother's milk from a spoon. Enjoin per- 
fect rest and apply ice to the stomach 'and hot water bags to the surface. 
Adrenalin solution, gtt. 5, or an aqueous solution of suprarenal extract 
(Gr. V to 5j), dose 10 gtt., may be given every half hour. Alum water, 



DISEASES OF THE NEW-BORN 



97 



1-20, may be used internally, in doses of ten drops, also as an enema. Styp- 
ticin, gr. % internally every hour, is useful. Two to four drachms of a 
sterile solution of gelatin may be injected subcutaneously or may be given 
by mouth or per rectum. 

Intussusception. — This is rare in the new-born, but of considerable fre- 
quency in early infancy. The symptoms are not pathognomonic, although 
vomiting, tenesmus, and mucus and blood in the stools suggest the pos- 
sibility of the condition. Abdominal palpation frequently reveals the 
presence of a tumor. Rectal palpation often establishes the diagnosis 
where other manipulations and symptoms fail to indicate the trouble. 
The introduction of water under moderate pressure into the rectum may 
effect the desired reduction of the tumor. Where this simple procedure 
fails, operative interference is indicated. Moreover, in these cases surgical 
interference should be prompt, as delay is hazardous. 

Umbilical Hernia. — This, as a rule, is readily reducible, and frequently 
recovery is spontaneous. A small button-shaped pad is laid over the 
umbilicus after reducing the hernia, and a strip of adhesive plaster applied 
to keep the pad in situ. Specially constructed pads and appliances are now 
to be had in the shops for this class of cases. 

Inguinal Hernia, where reducible, may be kept in place by applying a 
truss or by adjusting a worsted skein with the knot over the seat of hernial 
protrusion. In the reduction of hernia care must be exercised in the 
manipulation; an irreducible hernia demands surgical interference. Do 
not confound inguinal hernia with hydrocele. The former is translucent 
to transmitted light — the latter opaque. 

Operation for Hernia in Children. — An operation is seldom ad- 
vised under the age of four years except in strangulated cases. The reason 
for this rule is that many of these cases, probably two thirds, are cured by 
a truss. After the age of four years, in all cases in which a truss has been 
tried and failed, and in cases in which the presence of reducible hydrocele 
prevents a truss from holding the rupture, an operation is advised. The 
same rules hold good in irreducible omentum, a rare condition in childhood. 

Caput Succedaneum is the swelling which appears on the scalp intra 
partu. It disappears in due time and requires no treatment. 

External Cephalaematoma. — These swellings are due to blood extravasa- 
tions between the skull and pericranium, and most frequently are of trau- 
matic origin, caused by undue forceps pressure, prolonged labor, or mal- 
position with difficult delivery. They usually make their appearance a 
few days after birth, gradually enlarge, and are soft and fluctuating to the 
touch. Generally there are no associated evidences of inflammation, 
and the recovery is spontaneous, absorption taking place in four to sixteen 
weeks. Should infection and consequent abscess formation ensue, incision 
and drainage on antiseptic principles constitute the proper treatment. 

Internal Cephalaematoma. — This is a haemorrhage between the dura 
mater and the cranium, and may lead to all the manifestations of intracranial 
haemorrhage (apoplexy), viz. convulsions, paralysis, meningitis, and cystic 
degeneration, with recovery, idiocy, or death. An external hasmatoma 
may extend through a cranial fissure or fracture to the cranial cavity. 
The treatment is usually expectant, in the hope of spontaneous absorp- 
8 



98 



PEDIATRICS 



tion of the extravasation. Intracranial surgery has its limitations in the 
new-born. 

Haematoma of the Sternocleidomastoid is a firm, hard tumor of traumatic 
origin in the tract of the muscle. It disappears in time and requires no 
treatment except mild massage. 

Meningocele and Encephalocele are terms used to designate the pro- 
trusion of some part of the cranial contents through an opening in the skull. 
These conditions are analogous to spina bifida. 

Meningocele is a protrusion of a portion of the arachnoid fluid with its 
sac through one of the cranial openings and communicating with the arach- 
noid cavity. It is smooth, fluctuating, perfectly translucent, rarely pul- 
sating, and often reducible. Occasionally we meet with a meningocele in 
the nasofrontal region. The treatment by aspiration and injection with 
iodine is sometimes satisfactory and followed by permanent recovery, but 
hot always so. Marked reaction has followed operative procedure, and 
death from meningitis has taken place. An operation is justifiable in cases 
of impending rupture. 

Spurious meningocele from traumatic fissure of the cranium and dura 
is occasionally observed. The tumors are translucent, elastic, and generally 
small, and require no special treatment. If a differential diagnosis between 
hsematoma and meningocele must be made, an aseptic aspiration can be 
done. The elevation of a depressed bone may be indicated when epileptic 
seizures occur. 

In encephalocele the tumor is smooth, rarely pedunculated, and 
not translucent, and does not fluctuate. It contains meninges, fluid, and 
brain substance. Encephalocele is not to be confounded with hematoma. 




Fig. 38. — Encephalocele. 
Vault of cranium absent. Age one year. (H. Fischer.) 

In the former the swelling is situated at the fontanelles, or along the cranial 
sutures. Encephalocele increases and varies in size with the movements of 
respiration, and is often accompanied 'by cerebral symptoms. The treat- 
ment is by compression. The most pronounced case of this kind is one seen in 
consultation with Dr. H. Fischer, of New York. As shown in Figs. 38 and 39, 



DISEASES OF THE NEW-BORN 



99 



the top of the skull is absent and the brain is prolapsed into a sac formed 
by the scalp, and lies outside of the cranial cavity. At the age of six months 
the child was under the knife in one of our city hospitals, where the actual 
condition was not recognized. When the sac was opened and the brain 
presented itself, the surgeon saw his mistake and beat a retreat. The child 



at the present time is four years old and in good health, excepting occasional 
epileptoid attacks. 

Chondrodystrophy foetalis is, as its name implies, a faulty development 
of cartilage resulting in deformity. The causative factors of this condition 
are unknown. 

Stunted growth (achondroplasia) was formerly spoken of as fetal rickets 
or fetal cretinism. It differs from cretinism in the absence of the mental 
defects which characterize the cretin. There are two features in the limb 
bones which suggest, at first sight, a similarity to rickets. The one is cur- 
vature of the shafts, the other a prominence of the terminal epiphyses. But 
the bending in the case in question is not due to softness of the bones, as 
in rickets; on the contrary, the bones are quite firm and rigid. Moreover, 
there is no actual enlargement of the terminal epiphyses. The knobbed 
appearance in this case is explained by relative smallness of the shafts. 
In achondroplasia the bones resulting from ossification in membrane are 
formed as usual, but the parts which are ossified in cartilage in early fetal 
life are stunted in their development, as if from premature arrest of the 
ossifying process, and hence the defect in the long bones of the limbs, the 
ribs, the pelvis, and the greater part of the base of the skull and the con- 
comitant disfigurement of the skull and upper portion of the face. In 
most instances it would appear that the foetus, when the subject of achon- 
droplasia, either dies in utero or shortly after birth. Only a few patients 
have grown into childhood. 

Congenital Lipoma is an elastic, non-compressible tumor found any- 
where on the surface. It may disappear or persist, and need not be inter- 
fered with unless it gives rise to local disturbance or discomfort. 

Congenital Hygroma and Cysts. — These occur on various parts of the 
surface. Their accumulation of fluid contents can be removed by a 




Fig. 39 



'. — Encephaloce.le at Three Years. 



L4JFC 



100 



PAEDIATRICS 



simple incision. Should the fluid reaccumulate, the subcutaneous sac 
must be enucleated in toto under anaesthesia. Congenital cysts of the 
kidney are occasionally observed. 

Congenital Hydrocele. — The diagnosis of encysted hydrocele of the cord, 
hernia, and undescended testicle is sometimes difficult. A congenital 
hydrocele often disappears after a few weeks. 

Congenital Malformation of the Heart (blue babies). — Such ailments 
are of little practical importance; the children so afflicted frequently suc- 




Dwarf. N urinal. 

Fig. 40. — Achondroplasia. 



cumb to some intercurrent disease. Cases which at birth give evidence 
of a systolic murmur, which ultimately disappears, may be cases of per- 
sistence of the ductus arteriosus, which sometimes closes spontaneously. 
In blue babies with patency of the foramen ovale we may and may not 
hear a murmur. There is no active treatment for any of these cases. In 
some instances, owing to a profound disturbance of the circulation, the 



DISEASES OF THE NEW-BORN 



101 



suffering is so intense as to warrant the use of opiates or chloral hydrate 
at night. 

Enlarged Thymus Gland. — This condition may give rise to heart murmurs, 
respiratory stridor, and sudden death, as illustrated by the following case: 
An infant six weeks old was observed to be restless with spells of rapid 
breathing. A careful examination revealed a loud systolic murmur at the 
base of the heart which was not transmitted in any direction and which 
did not take the place of the systolic click of the valves. The heart dul- 
ness extended upward and laterally beyond the normal. The baby had one 
or two convulsions, from which it rallied promptly. It died very suddenly 




Fig. 41. — Enlarged Thymus. (Dr. Cox.) 



without premonitory signs. At the autopsy the heart was found to be 
intact, the ductus arteriosus was closed, and the thymus gland was very 
large and so located as to encroach by pressure upon the lumen of the aortic 
arch and pulmonary artery. It may be of practical importance to know 
that the enlarged thymus gland may be recognized by percussion upward 
as the child is held face downward. The removal or high fixation of an 
enlarged thymus gland is a surgical possibility. See also article on the 
Thymus. 

Birth Palsies. — These in a majority of instances are the result of pressure 
or injury induced by artificial delivery (with forceps), or in prolonged labor 
from undue pressure by the maternal parts. In difficult labor (breech 
presentations) the parts involved are usually one or more of the extremities, 
Erb's paralysis being a familiar type in which the upper arm is involved. 
Facial palsies due to pressure of the forceps on the facial nerve are not of 



102 



PEDIATRICS 



rare occurrence. Forceps neuritis of the neck is another form. Cerebral 
palsy, a result of haemorrhage at the base of the brain, is still another 
form. The treatment of the types commonly met with is by faradism, 
galvanism, vibration, and massage. In instances where injury to the nerve 
supply is extensive and no response to treatment ensues after a few weeks, 
permanent paralysis with accompanying atrophy of the muscles supplied 
ensues, and the use of the limb is impaired. Nerve suture and nerve 
anastomosis are surgical possibilities (see also Neurological Memoranda). 



DEFORMITIES; MALFORMATIONS 

Common Forms 

Hare lip and cleft palate are among the most frequent of congenital 
deformities. Their treatment is strictly surgical, but operative interference 
should not be resorted to at too early a period. It is wise to wait until 
the child acquires a little vigor and is better able to withstand operative 
measures. Meanwhile the mouth, nose, and throat should be kept scrupu- 
lously clean. If the infant cannot nurse well as a result of the deformity, 

it may be necessary to temporarily feed it 
artificially by means of a specially con- 
structed nipple with a rubber flap at- 
tachment which adapts itself by the 
suction to the opening in the palate. 

Imperforate anus and rectal stenosis 
demand early relief. The simple variety 
of cutaneous anal atresia is easily reme- 
died by simple incision and digital dila- 
tion. Atresias higher up in the rectum 
require skilful dissection by the surgeon. 
Atresia of the rectum with communication 
between rectum and vagina is occasion- 
ally found. In such cases the faecal mat- 
ter escapes through the vulva. If there 
is no obstruction to the passage of fasces, 
operative interference should be delayed 
until the parts are large and more de- 
veloped. 

Tongue tie exists more in the imagi- 
nation of the mother of a child than in 
fact. Whenever the frenum of the tongue 
is too short, put the tongue on the stretch 
by inserting two fingers into the mouth 
under the tongue, and cut the frenum with blunt scissors while it is on 
the stretch. Bifid tongue and bifid uvula are occasionally met with. 

Spina Bifida. — This is a not uncommon malformation of the spinal 
canal with a cystlike protrusion of its contents — cerebrospinal fluid. The 
elastic and compressible tumor may be simply a meningocele (membrane 
and fluid) or meningomyelocele (membrane, cord, and fluid). Spina bifida 




CONGENITAL DEFORMITIES ; MALFORMATIONS 



103 



is readily recognized, but it is occasionally difficult to tell which variety 
we have to deal with. The simple spina bifida frequently heals spontane- 
ously. The bony aperture closes and the cystic sac dries up. Under all cir- 
cumstances the tumor must be kept clean and protected by cotton batting. 
Simple aspiration and compression 
are usually of no avail. When there 
is no danger of rupture, operative 
interference is not urgent and may 
be deferred until the child is older. 
Aspiration and injection of iodine 
solution is a procedure not free from 
danger. Ligature and excision of 
the sac is a safe operation. Plastic 
operations with an attempt at clo- 
sure of the aperture by flaps of 
neighboring periosteum have been 
attempted with varying success. 
In the worst cases there is paralysis 
of the bladder and rectum. 

Hypospadias. — In this condition 
the urethra opens on the inferior 
surface of the penis. In front there 
is only a shallow furrow. In severe 
cases there is a deep fissure which 
divides the scrotum, and when in ad- 
dition the testicles are undescended, 
the case is erroneously taken for 
hermaphroditism. 

Epispadias. — The urethra opens 
on the dorsal side of the penis, and FlG . 43 ._ Thoraco abdomino Pagus. 
the condition may be complicated (Dr. Sheffield.) 

by exstrophy of the bladder. An 

analogous deformity is met with in girls. All these deformities are com- 
patible with long life, and can be removed in many cases by a plastic 
operation. 

Cryptorchidism, or undescended testicle. In foetal life the testicles 
are situated in the abdominal cavity, below the kidneys. In about 10 per 
cent of all children they fail to descend into the scrotum at full term, but 
come down during the first few weeks of life. When one remains in the 
inguinal canal, it should be let alone imless very painful, when it should be 
removed, or better, an attempt should be made to put it into its proper 
place. 

Phimosis. — This condition is frequently met with and varies in degree. 
Where there is simply a short prepuce with moderate epithelial adhesions, 
the condition may be corrected by stretching. When the prepuce is long, 
and stretching will not remedy it, circumcision is resorted to; but this 
operative procedure may be delayed until about the ninth month if there 
is no difficulty in micturition. The method is as follows: Under general 
ansesthesis the prepuce is drawn forward, placed between the blades of a 




104 



PEDIATRICS 



narrow artery forceps, and the presenting portion snipped off with scissors. 
On removing the forceps, the redundant inner {or mucous) layer presents 

itself, which is removed in the same 
way, and a few sutures of black silk 
are inserted in such a manner that 
the bleeding vessels are also included. 
A mild antiseptic ointment is ap- 
plied, the part placed in suitable 
lint, and the diaper applied. The 
sutures may be removed about the 
fifth day. The object of applying 
black sutures is that they may be 
readily detected when the time for 
their removal arrives. A simpler 
method, very often satisfactory, is 
to cut a short distance into and 
along the dorsal aspect of the pre- 
puce until the glans is exposed, and 
take a stitch in either flap of the 
prepuce so cut and dress aseptically. 
Unrelieved phimosis, on account of 
local irritation, may affect the gen- 
eral health of delicate children. 

Web Fingers and Toes; Super- 
numerary Digits. — These call for 
plastic surgery or extirpation. Club 
foot and other deformities due to undeveloped conditions or as the result 
of intrauterine constricting bands call for special orthopaedic and surgical 
treatment. (See chapter on Orthopaedics.) 




Fig. 44. — Thoraco Abdomino Pagus. 
(Skiagram). 



Rare Forms 

Atresia Oris; Microstoma. — The lips are grown together entirely or sepa- 
rated by a small opening. This malformation is usually due to syphilis 
and necessitates constitutional treatment and a cheiloplastic operation. 
Atresia pupillse congenita is a rare malformation in which spontaneous 
improvement usually occurs. Atresia of the small intestine is rare. The 
symptoms are early and persistent vomiting. Nothing passes from the 
bowels after the meconium has escaped. Death occurs within a week 
unless operative interference is successful. Atresia urethras is generally 
epithelial, but occasionally membranous; blunt pressure or an incision will 
overcome the obstruction. Atresia vaginae hymenalis usually escapes ob- 
servation until puberty, and then requires incision and packing. Cloaca 
congenitalis. In the absence of the anus the rectum may end in the blad- 
der, vagina, or urethra. This condition may be remedied by operative 
interference. 

Congenital Hypertrophic Stenosis of the Pylorus and Duodenum. — 

This is a far more frequent affection than is supposed, but the condition 
is not generally recognized, as the symptoms may easily be misinterpreted. 



CONGENITAL DEFORMITIES ; MALFORMATIONS 



105 



The essential feature of the morbid anatomy is the thickening of the circular 
muscular fibres of the pylorus or a fibrous thickening. 

Diagnosis. — Vomiting, dilatation of the stomach, and visible gastric 
peristalsis with emaciation are marked features. Dyspeptic symptoms are 
first noticed, and subsequently the dilatation of the stomach and obstinate 
constipation point to an obstruction in the course of the gastroenteric tract, 
but the pyloric tumor is not felt, on account of abdominal tympanites. 
When the stomach contents are siphoned out they are generally found 
to contain bile. In some instances the bowels move tolerably well until 
a few days before death. In the majority of the cases reported the initial 
symptoms were noticed during the first two weeks of life; in one or two 
instances as late as in the third or fourth month. 

Treatment of Congenital Pyloric Stenosis. — The feeding should 
be regulated, and the stomach may be washed with a ^-per-cent solution of 
Carlsbad salt in water. Drugs are useless ; massage may be employed 
and a stomach binder applied. 
If necessary, rectal feeding may 
be employed. In extreme cases 
pyloroplasty is indicated. Digi- 
tal divulsion of the pylorus 
(Loreta's operation) is not feas- 
ible in infants. Before opera- 
tive interference is attempted 
mild forms of Spasmodic Stric- 
ture must be excluded. Muscu- 
lar hypertrophy at the pylorus 
may be secondary to overaction 
of the sphincter, and injudicious 
feeding may be a contributing 
factor to spasm and nervous 
incoordination. 

Bronchocele and a Branchial 
Fistula. — Persistent congenital 
conditions as the result of im- 
perfect closure and development 
of the branchial arch are strictly 
surgical conditions and call for 
surgical interference. 

Congenital Pharyngooeso- 
phageal Stenosis is a very rare 
malformation in which the up- 
per part of the oesophagus at 
its junction with the pharynx 

ends in a blind pouch. A case of this nature was reported to the American 
Pediatric Society in 1896 by S. S. Adams, M.D., of Washington, D. C. 

Congenital Stenosis of the Larynx is rarely observed. The infants, 
instead of crying, emit a muffled sound. 

Cranial Asymmetry. — This is no unusual occurrence. It is due to ante- 
natal trophoneurotic, rhachitic, or syphilitic disturbances. 




Fig. 45. — Bronchocele. 



106 



PEDIATRICS 



Umbilical Fistula. — The common form is an umbilical conical tumor 
with a fistula at its summit representing the remains of an embryonal forma- 
tion known as the omphalomesenteric duct. These tumors are of various 
sizes, pink in color, with an oozing discharge from the centre. They may 
become obliterated or be cured by ligature. The large tumors of this 
nature require careful surgical dissection. 

Stigmata of degeneration and manifold deformities are observed which 
usually present more of a surgical than medical aspect. The same is true 
of malformations and monsters. 

Wormian Bodies. — When ossification of any of the tabular bones of the 
skull proves abortive, the membranous interval which would be left is 




Fig. 4C. — Marked Curve in Little Finger of Mongolian Idiot. (Dr. West.) 

usually filled in by a supernumerary piece of bone. This is developed from 
a separate centre, and gradually extends until it fills the vacant space. 
These supernumerary pieces are called Wormian bones (after Wormius, a 
Copenhagen physician). They are also called, from their usual form, 
ossa triquetra, but they present many variations in situation, number, and 
size. They occasionally occupy the situation of the fontanelles. 

Congenital fissures and gaps are occasionally found in the cranial bones, 
the result of incomplete ossification. They extend from the margin toward 
the middle and might be mistaken for fractures. In hydrocephalic skulls 
they are most frequent in the frontal bones and in the parietal bones on 
cither side of the sagittal suture. 

Maternal Impressions. — Strong impressions of terror, pain, disgust, etc., 
experienced by the mother during pregnancy are supposed to be responsible 



BREAST FEEDING 



107 



for bodily defects in the infant, such as hare lip, cleft palate, club foot, moles, 
strawberry marks, etc., but this has not been proved. Pending a final 
decision on this obscure subject, it may be well to guard a woman during 
pregnancy as much as possible from unpleasant impressions. 

Fractures. — An infant's cry indicative of pain, disability as to motion, 
dimpling of overlying tissues, and swelling of the soft parts, leads to the 
diagnosis of fracture. A displacement shown by the radiograph is conclu- 
sive evidence. Fractures may be antenatal or occur at birth from ab- 
normal conditions present or from traumatism in precipitate or difficult 
labor. The common fractures are those of the humerus, the clavicle, the 
femur, the cranial bones, etc. 

Infant Mortality. — Ten per cent of the new-born are lost from various 
causes before they are one month old. Responsible for this mortality are: 

Maternal causes before and during labor, including protracted labor 
and asphyxia. 

Fcetal causes are antenatal disease and accidents, multiple preg- 
nancy, malposition and excessive size of the child, congenital feebleness 
and prematurity, and convulsive disorders. 

Sudden death of infants is not an infrequent occurrence from manifold 
causes which usually cannot be elicited except through an autopsy. 

INFANT FEEDING 

BREAST FEEDING; MATERNAL NURSING 

General Considerations 

It may be regarded as axiomatic that every healthy mother should 
nurse her own baby. A mother's milk is the natural food of the infant 
and is more in harmony with the special requirements of the offspring than 
any substitute form of nourishment. This close tie between mother and 
child must not be severed on insufficient grounds. No kind of bottle food 
can compete with the milk from a healthy breast; a perfect substitute 
for the healthy human breast milk is and always will remain an impossibility. 
Infants, however, do not invariably thrive at the breast, and it therefore 
becomes necessary for the intelligent practitioner to acquaint himself with 
the composition of human milk, that he may be able to recognize what ele- 
ments or factors are at fault in a case of infantile indigestion in a breast fed 
child, that the condition may be remedied or that an artificial food may 
be substituted. This must have as its basis, under all circumstances, the 
composition of breast milk. Breast fed children not alone show indigestion 
in its various phases, but not infrequently have rhachitis, scurvy, or cholera 
infantum; and much of the success of the family practitioner will depend 
upon his knowledge of the dietetic management of the breast and bottle 
fed child. 

It will be well to keep in mind a few physiological points in reference to 
the composition of human breast milk and the conditions influencing the 
uniformity of its composition-. ' A good breast secretes from one to three 
pints daily and is emptied in about fifteen minutes. The milk has a 



108 



PEDIATRICS 



specific gravity of about 1.030, and is of the following composition, with 
variations: 



The so called "fore milk " consists of about 10 per cent solids and 90 per 
cent water; the "stripping," of 15 per cent solids and 85 per cent water — 
this difference of 5 per cent in the composition of fore milk and stripping 
it is important to note, as we shall presently see. According to Johannsen, 
the highest percentage of solids is noticed about three p.m. daily; the lowest 
percentage of fat during the night, when it sinks to 1 per cent. 

The average stomach capacity of a healthy infant is about as follows: 



The average gain of a healthy infant at the breast is about half an ounce 
a day. 

The stomach capacity of breast fed children in general is less than 
that of artificially fed children. The capacity of a healthy stomach is 
smaller than that of a functionally inefficient stomach. Large capacity 
may be due to a narrow pylorus; large stomachs without pyloric stenosis 
are usually overdistended stomachs. It has been quite conclusively estab- 
lished that very little fluid is absorbed from the stomach; we must as- 
sume, therefore, that in cases in which there is no gastrectasia, the quantity 
of milk frequently taken in excess of the normal stomach capacity is 
never completely retained at one time in the stomach, but oozes through 
the pylorus into the intestine and does not so frequently overtax the 
stomach of otherwise healthy infants as is supposed and feared. On the 
other hand, in motor insufficiency, from anaemia and other causes, over- 
feeding may produce disastrous results and conditions in infants as well 
as in adults. Among the many conditions affecting the composition of 
breast milk we may bear in mind the following: Age of the mother; num- 
ber of pregnancies; nervous influences (epilepsy, convulsions, worry); diet 
of the mother; exercise of the mother; regularity of nursing; menses; acute 
or chronic illness (e. g., tuberculosis, syphilis, nephritis, typhoid, cancer); 
suppuration of the breast — sepsis; cachexia from other chronic or acute febrile 
disease; drugs. 

Hence, as influenced by these factors and conditions, we may have: 
a. Overrich milk; b. Abundant normal milk; c. Scanty normal milk; 
d. Abundant poor milk; e. Scanty poor milk — producing in the infant, 
sooner or later, no gain or loss of weight, colic, no sleep, bad stools, with 
or without fever, incessant crying for food, rhachitis, scurvy, etc. 

Nursing mothers over forty years of age do not have rich milk as a 



Water 



88 per cent 



'Fat. 
Proteids. 



Solids 




At birth 

" 2 months .... 

" 6 months 

" 12-14 months 



1 ounce. 
3 ounces. 
6 ounces. 
9 ounces. 



BREAST FEEDING 



109 



•ule, and the same holds good for mothers who have borne children in rapid 
;equence. The milk of neurotic or emotional mothers is far from normal, 
md is not apt to be influenced very favorably by judicious management. 

The diet and exercise of the nursing mother are of great importance in 
the production of good milk. Liberal feeding and no exercise will frequently 
rive an overrich milk with 6 per cent of fat; hard work together with 
poor food is responsible for a very poor milk with less than 1 per cent of 
fat. Irregularity in nursing makes good milk bad, and frequent nursing 
is found to give a concentrated milk and produce colic in the child; too 
prolonged intervals in nursing are apt to decrease the total solids and 
produce a milk easily digested but not nutritious. A very concentrated 
milk may be nutritious, but is difficult to digest. 

Acute and chronic illness often occasion bad breast milk, particularly 
such diseases and conditions as tertiary syphilis, nephritis, typhoid, and 
sepsis. The milk from a suppurating breast is not proper food for an 
infant, and it has been alleged that pus taken with the breast milk is 
occasionally responsible for multiple furunculos's in infants. During the 
catamenial period the breast milk changes in composition, inasmuch as 
the fat percentage is low; but, as this period of depression lasts but a few 
days and former conditions are again established, the appearance of the 
menses is not a direct contraindication for the breast. Finally, it is well 
to remember "that all secretory and excretory organs of the body are in 
close touch with the general circulation, and powerful drugs are apt to 
exert their effects upon an infant through the medium of a nursing mother. 

The following analysis, taken from Rotch, expresses in percentage the 
various changes in the composition of breast milk: 



Normal. 


Catamenia. 


Starvation. 


Overrich. 


Neuropathic 
constitution, 
pregnancy, 
diseases. 


Fat 4. 


11 


1. 


5-6 


3. 
i 


Sugar 7 . 


6. 


4. 


7. 


5. 


Casein 1J 


21 


2i 


Si 


44 



Contraindications for Breast Milk. — Tuberculosis, cancer, syphilis, 
epilepsy, any form of sepsis, cachexia from chronic or subacute disease, 
very acute illness, convulsive attacks — all of these conditions are prime 
indications for weaning. In a case of sore nipple without suppuration of 
the gland the milk may be pumped from the breast and fed from a breast 
bottle. 

In case of pregnancy or gradual diminution of the milk supply of the 
mother, it will not be necessary to wean suddenly. If possible, wait for 
the approach of cold weather before taking the child from the breast, 
gradually substitute other food, and have no regard for dentition. When 
the breast supply gives out gradually, it is a very good plan to give half 
breast and half bottle food. The selection of the latter will depend upon 
circumstances. All things being equal, diluted top milk, sterilized in warm 
weather, should be selected (see cow's milk for infant feeding). 



110 



PEDIATRICS 



How to Influence the Composition of Mother's Milk 

If a child at the breast shows symptoms of dyspepsia and no gain in 
weight, study the conditions affecting the composition of the mother's milk 
as discussed in the foregoing remarks, and if possible determine the 
amounts of fat and proteids in the milk. If the milk is overrich, the 
mother is to be placed upon a plain diet; and the inactive, phlegmatic, 
lazy mother should be made to engage in active exercise (e. g., walking). 
If the milk is poor in the beginning of nursing, appropriate efforts should 
be made to increase the percentage of fat by allowing the mother a liberal 
diet of albuminoids (eggs, meat), and curtailing exercises. Liquids (beer, 
porter) increase the flow of milk, but do not enhance its richness. Fat 
does not increase fat. (See article on Diet.) 

In making an analysis of milk for practical purposes we have to inquire 
into the percentage of fat and casein therein contained. The microscopical 
and specific gravity tests are uncertain and furnish no very definite data. 
The Babcock and other centrifuge tests for fat are adaptable for labora- 
tory use and purposes. Many physicians are fortunate enough to be able 
to rely upon the services of a friendly apothecary for ordinary analysis. 

To approximately determine the percentage of fat present in the milk 
under investigation, a small calibre test tube graduated from 1 to 100 is 
filled to the 100 mark with milk pumped from the breast, an indefinite 
quantity of ether is added thereto, and the contents are thoroughly shaken. 
After the lapse of half a day, on standing, the liquid separates into two 
layers, ether and fat, and milk minus fat; then, for example, if the point 
of demarcation between the two layers is at 97, we have 3 per cent of 
fat represented in the specimen examined. We now decant the ether and 
fat solution and precipitate the casein contained in the skim milk by the 
addition of acetic acid or rennet; the curd formed is then collected on a 
filter (the weight of the filter being known), and the salts, etc., are washed 
out with water; filter and curd are dried in an oven and weighed together. 
Deduct the weight of the filter from the total weight and the weight of the 
curd remains; thus, e. g., if in a test tube graduated in grammes the weight 
of the curd was found to be 2.0 gm., the percentage of proteid is two, 
approximately. An inexpensive Swiss milk tester in the shape of a flat 
disc can now be obtained, which enables one to tell rich from poor milk 
at a glance. Holt has devised an inexpensive milk tester. 

Summary 

Overfeeding, excessive fats or proteids, may cause dyspeptic symptoms 
in the nursing infant. Proteids and fat in mother's milk may be increased 
or diminished in many cases by diet and exercise. A deterioration of the 
breast milk occurring early or toward the end of lactation is accompanied 
by insufficient gain or loss of weight in the child unless the condition of 
the milk can be improved or an addition made to the child's diet. The 
proteids are high during the colostrum period, and may provoke dyspeptic 
symptoms in the premature or full term infant. 

The dietetic management of infants is not solely a question of ac- 
curate percentages of fat, casein, and sugar; the composition of breast milk 



MOW TO NURSE 



111 



varies within certain limits all the time, in the healthiest individuals; it varies 
from day to day and varies within the day. Those who attempt to regulate 
the physiological processes occurring in the animal economy by methods 
brimful of mathematical accuracy, viewed solely from the standpoint 
of chemistry, are as much at fault as those who make no attempt to 
study and understand the subject. The chemical behavior of food stuffs 
in the laboratory is entirely different from the chemical behavior in the 
animal economy. Conclusions drawn from such comparisons as practi- 
cally applicable to the necessities and workings of the human economy are 
frequently grossly erroneous. In our attempts to aid and imitate nature, 
common sense will establish limitations and keep us away from gross scien- 
tific errors. 

HOW TO NURSE 

The new-born child may be put to the breast after the mother has had 
a refreshing sleep. In the mean time or in case the milk is somewhat 
delayed, it may receive warm and sweetened fennel tea. Should the milk 
be delayed beyond the second or third clay, artificial feeding must be done 
at regular intervals. Almost all infants can be trained to nurse and sleep 
regularly. Mothers and nurses who fail to appreciate this fact, or lack the 
necessary firmness and common sense, will suffer much wear and tear during 
the nursing period. For the first two months ten feedings a day are the 
average, including two night nursings; and it should be the aim of the 
mother or nurse to accustom the child to abstinence and sleep for four to 
six hours at night. As the child grows older, the intervals between nursings 
increase, and one night nursing will suffice. 

After the child is six to eight weeks old, it should be taken out of doors 
in all but stormy weather for from two to six hours each day. The sleeping 
room should not be heated above 65° to 68° F. Children kept indoors in 
overheated apartments become dyspeptic in a short time. Medication in 
such cases is absurd — fresh air to breathe is Nature's tonic and digestant. 

Wet Nursing. — If maternal feeding is out of the question, a good wet 
nurse is to be preferred to artificial feeding. It is the writer's experience 
that children artificially fed, all other factors being equal, succumb more 
readily to severe infectious disease than do breast fed children. At the 
same time it must be emphasized that in private practice infants can be 
raised on the bottle without much difficulty. The moral question involved 
in depriving an infant of a poor mother of its natural nourishment is usually 
not taken into serious consideration, but, inasmuch as a healthy woman 
with full breasts can readily nourish two infants until they are several 
months under way, such an arrangement might well be suggested by a 
well meaning physician. 

In selecting a wet nurse, the physician will investigate carefully as to 
marked anaemia, syphilis, tuberculosis, gonorrhoea, the condition of the 
breasts, nipples, lymph nodes, etc.; and endeavor to secure for the nurse 
the proper diet and sufficient rest to insure if possible an adequate supply 
of good milk. A wet nurse need not be rejected if her child is four or six 
weeks older than the one to be nursed. 



112 



PEDIATRICS 



Weaning. — Deterioration in human milk is marked by a reduction in 
the proteids and total solids. This deterioration takes place normally 
during the later months of lactation, and is accompanied by a loss of 
weight, or a gain below the normal standard, unless supplementary feed- 
ing is established. Deterioration may be the forerunner of the cessation 
of lactation, or well directed treatment may improve the condition of the 
milk. 

Weaning should be done gradually and if possible in cold weather, with 
no regard to the period of dentition. Any sudden change in food is apt 
to be followed by indigestion. Sudden weaning may be required in severe 
acute illness of the mother, but if this is of short duration, it is often wise 
to keep up the flow of milk by means of the breast pump. 

In weaning, the artificial food must be of low strength at first, with a 
gradual increase in the strength of the milk food. The mother is made 
more comfortable by a binder holding up the breasts. The management 
of inflamed breasts and sore nipples is discussed elsewhere. 

Mixed feeding is a combination of breast and bottle feeding, and in many 
cases is superior to artificial feeding alone. 

1. The breast milk may be good, but lacking in quantity. 2. It may 
flow well, but be poor in fat. As regards point 1, we can make the intervals 
between the nursings longer and feed by bottle once, twice, or three times. 
As regards point 2, we can endeavor to increase the richness of the breast 
by a special diet for the mother and feed by the bottle several times a day, 
and thus continue lactation for a long time. Mixed feeding is often necessary 
in retarded convalescence after parturition. 

No Drugs for Nursing Infants. — The medicinal mismanagement of dys- 
pepsia, or indigestion, in nursing infants is one of the greatest wrongs that 
a medical adviser can inflict upon the innocent and helpless. Indigestion 
in nursing infants is managed by diet, abstinence, fresh air, and rectal 
enemata, and not by drugs. The following case from the writer's experience 
will serve as an illustration for these remarks: 

A breast fed infant seven days old had a dyspeptic diarrhoea three days 
after birth. Instead of cutting off the breast milk for a short time and 
feeding on farinaceous water, in order to give the gastroenteric tract a chance 
to readjust itself, the infant was at once drugged according to the prevailing 
fashion, and calomel, lactopeptine, bismuth, and salol were given in rota- 
tion. As there was no improvement, resorcin was ordered in quarter grain 
doses every four hours, and after the sixth dose of this drug the child became 
cyanotic, pulseless, clammy, and cold, and the urine which had been voided 
before collapse set in was smoky in color. Resorcin poisoning was at once 
suspected, and the subsequent management was as follows: The child was 
given a hot bath, 110° F., every two hours and kept warm by hot water 
packs, the bowels were flushed with a warm saline solution every three 
hours, and warm sweetened tea was given by a spoon frequently. The 
child recovered completely in the course of a few days and again took the 
breast at regular intervals and remained well. 



FACTS ABOUT MILK 



113 



FACTS ABOUT MILK 

As cow's milk is the basis of artificial infant feeding, its properties 
and the various methods of its handling and its modification should be 
thoroughly understood by the practitioner. For that reason some extra 
space in this volume is devoted to the important subject of milk and milk 
diluents. 

Guaranteed, or certified, milk is pure, clean milk for the nursery as fur- 
nished by dairymen under the following safeguards: (1) The veterinary 
care of the herd and its protection against tuberculosis, sepsis of the udder, 
and other infectious diseases of the cow herself. (2) The medical care of 
the attendants in regard to their health, the hygiene of their homes, and 
the practical quarantine of the farm. The carefid sterilization of the milkers' 
clothing and the cleanliness of their hands and arms during the process of 
milking. (3) The care of the cows, the absence of manure in the barns, 
the practical exclusion of faecal matters from the milk, and precautions 
against the entrance of dust. (4) The extraordinary precautions placed 
around the milk in the milk house and in the processes of transportation 
and delivery. 

Standard of Cleanliness 

It has seemed wise to establish a standard of cleanliness, or a bacterial 
standard, to which dealers must conform. The standard prescribed by 
the commission of the Medical Society of the County of New York, and of 
the medical commission of the Walker Gordon Milk Laboratory, and of 
similar commissions in other cities is that the acidity must not be higher 
than 3 per cent, that the milk must not contain more than 30,000 germs, 
or bacteria, of any kind per cubic centimetre, and that the butter (fat) 
must reach 3.5 per cent. 

Out of twenty samples examined on a winter day, November 19th, the 
smallest number of germs found was 90,000, and the highest 2,280,000, 
while on June 29th, with the thermometer at 90°, out of twenty sam- 
ples examined, the smallest number found was 240,000, and the highest 
516,000,000 per cubic centimetre. The prevalence of bacteria, to a great 
extent, arises from the dirt of the milk. "There are seven conditions on 
which the amount of bacteria depends — the cleanliness of the barn, condi- 
tion of the cow, condition of the milker, condition of the utensils, the cooling 
process, the transportation, and the cleaning of the milk bottles before 
they are returned." 

Aeration is not a success to-day as used by the ordinary farmer. In 
good hands it might work all right, but in many cases, as at present used, 
it results in an increase of germs. The three things which are absolutely 
necessary to secure milk comparatively free from germs are strict cleanliness, 
rapid and sufficient cooling, and thorough icing of the milk until it reaches 
the consumers. In the transportation of milk ordinary freight cars should 
not be used, and the ends of the cars should be kept closed, thus preventing 
the heated air from passing through the car and breeding the germs. The 
railroads could be asked to cooperate and furnish refrigerating cars in which 
the milk could be kept constantly on ice, and after being unloaded it 
9 



114 



PAEDIATRICS 



should be re-iced before reaching the dealers. Milk not coming up to this 
standard and cheap milk purchased in grocery stores in large cities are 
absolutely unfit for infant use, and raw milk should not be fed to infants 
unless it is guaranteed at the above described standard of cleanliness. 

Modified Milk ; Adapted Milk. — These terms are used in connection with 
cow's milk which has been modified or adapted by dilution to the needs 
of the infant. Milk may be modified in the household or may be pur- 
chased already modified from the various milk laboratories long since 
established in all large cities. The laboratory modifications are naturally 
higher in price than household modifications. 

Sterilized and Pasteurized Milk. — During hot weather the infant's 
food should be Pasteurized — heated to 167° F. — or sterilized — heated to 

212° F. The bottles of food may be set in 
a kettle of water with a thermometer. 
Heat rapidly to 167° F. and keep the water 
at this temperature for twenty minutes; 
then cool the food rapidly and keep it cool. 

Combined Pasteurizers and sterilizers 
can now be bought with full directions 
for using. Pasteurizing or sterilizing does 
not increase the digestibility of the food, 
but prevents the growth of germs that 
spoil the food and cause sickness. 

Rationale of Milk Sterilization 

A few words as to the rationale of milk 
sterilization. All of our food, liquid or 
solid, is perishable, and we associate with 
this process of organic decay the terms fer- 
mentation and putrefaction as represent- 
ing those processes in nature by which 
organic substances are split up into their 
elementary constituents, such change being 
usually accompanied by the formation of 
poisonous by-products — ptomaines and 
toxalbumins. In order to hinder a rapid decomposition of our food, we 
make use of methods of preservation, and employ for that purpose in the 
laboratory, as well as in the household, the high and low temperature re- 
spectively known as the freezing and boiling point of water. Now, one of 
the most important, and at the same time one of the most unstable, articles 
of food which enter the household of the rich and poor is cow's milk; and 
as we know at the present time that spoilt milk is the chief factor in the 
causation of summer diarrhoea, we have naturally come to the conclusion 
that the ordinary methods of preserving milk in the "household are faulty, 
especially as regards the manipulation of milk intended for infants' use, and 
the suggestions of the German chemist, Soxhlet (whose method of steriliz- 
ing milk in the household is well known in all civilized countries), have been 
most enthusiastically accepted and mark a distinct advance in the rational 




Fig. 47. — Arnold Sterilizer and 
Pasteurizer. 



STERILIZED MILK 



115 



prophylaxis of acute gastrointestinal disease. Since the introduction of 
Soxhlet's method to the American profession by the writer, in 1887, 
numerous milk sterilizers have been launched upon the public. The 
different forms of apparatus now obtainable in this country are all con- 
structed on correct scientific principles, and no special designation need be 
made in favor of one or the other. The Arnold sterilizers can be used both 
for Pasteurizing and sterilizing. 

One point must be borne in mind, however : there is no apparatus on the 
market which will make innocuous such milk as already contains the chem- 
ical products of decomposition — the ptomaines. The milk which we subject 
to the sterilizing process should be pure and fresh, otherwise we shall fail 
in our object. Infant mortality in New York city during the hot weather 
has markedly decreased since the introduction of the sterilizing process, 
and depots for the sale of sterilized milk have been established where the 
poor can obtain such milk for about one cent a feeding. 

Sterilizing at a low temperature does not destroy pathogenic germs in 
milk. The question of the transmissibility of the bovine tubercle bacillus 
to human beings is, according to Koch's experiments, sub judice. The 
assumption that the sterilizing process is responsible for the condition 
known as scurvy is erroneous. The Arctic explorer, Dr. Nansen, personally 
told the author that during his three years' trip not one case of scurvy 
developed among his men, and he attributed their immunity to the thor- 
ough sterilization of all perishable food. 

In household sterilization the milk food is steamed in a set of bottles, 
each containing sufficient food for a single feeding, i. e., enough for twenty- 
four hours. The rubber stoppers usually furnished with the steamer are 
to be used only when the milk is to be preserved more than a day or two 
(on a voyage, for instance). Ordinarily a firm pledget of non-absorbent 
cotton is twisted into the neck of the bottle before the heat is applied. 
The bottles are so constructed that they can readily be cleaned; and in 
feeding, the cotton is removed and an ordinary black rubber nipple is 
adjusted. 

In a recent elaborate report issued by the Wisconsin Agricultural College, 
steaming for twenty minutes at 140° F. is recommended as a safe procedure 
for preserving infants' food from day to day. But it must be borne in mind 
that milk food steamed at a temperature below the boiling point of water 
(212°) will not keep sweet unless rapidly cooled and kept on ice. 

In traveling with infants and young children the ordinary milk obtain- 
able in transit must not be used. An adequate supply of sterilized milk 
food should be carried along. This can be prepared in the household or 
secured from a milk laboratory such as those now established in all large 
cities, or condensed milk or evaporated cream can be carried along and 
diluted with boiled water (1 to 12). 

Pancreatized Milk (Peptonized Milk) 

This is predigested milk prepared with the aid of a "peptonizing 
preparation " which is sold in glass tubes, with full directions for its use. 
In ordinary cases of acute and chronic milk indigestion the writer seldom 



116 



PEDIATRICS 



makes use of pancreatized milk. Its use is indicated occasionally for a 
week or two in cases of acute febrile illness, when the stomach is so rebel- 
lious as to reject almost everything put into it, and it is serviceable for 
rectal alimentation whenever it is indicated. Peptonized milk has a bitter 
taste, and children are not fond of it, and it is never indicated as a regular 
food for healthy children. 

Directions for Peptonizing Milk. — Cold Process: 

Pancreatin gr. v ) , , . , 

„ , , . , > make 1 pint. 

Sod. bicarb., gr. xv ) 

Mix the sodium bicarbonate and pancreatin in a cup of cold water. 
Add a pint of cold milk and then shake well and place on ice. 

Hot Process. — Prepare as above directed, but place in a dish of 
water at a temperature of 115°, and keep there for ten minutes. Then 
place on ice. 

Buttermilk. — As nourishment in subacute and chronic diarrhceal dis- 
ease of infants buttermilk has been recommended by Dutch physicians. 
Some very satisfactory results following its use in older children and con- 
valescent adults have been observed. 

Condensed Milk and Evaporated Cream. — Milk kept in grocery stores 
is unfit for infants' use. When parents are unable to buy pure certified 
milk or are not intelligent enough or willing to handle it properly, fresh 
condensed milk may be fed. It must be diluted with boiled water or barley 
water or oatmeal water in the following proportions: 1 to 12 for the first 
month; 1 to 10 for the third month; 1 to 8 for the sixth month. 

If fresh condensed milk is used, sugar and cream must be added. Canned 
condensed milk is sufficiently sweet and does not require additional sugar. 
Condensed milk sufficiently diluted to bring down the percentage of casein 
to the breast milk standard will require the addition of cream or fat. Evap- 
orated cream in cans may be used for this purpose. Each feeding should 
be separately prepared. Feeding on condensed milk is not expensive and 
is simple as regards its preparation, but the results are not so satisfactory 
as with fresh and pure cow's milk. 

Asses' and Goat's Milk for Infant Food. — Feeding with asses' milk has 
given good results, and is frequently employed in France. Children take 
about one quart of milk a day. Asses' milk comes nearer to human milk 
than any other, but contains a low percentage of fat (one half of 1 per cent), 
and is not adapted for more than the first two months of infancy. Goat's 
milk contains a high percentage of fat. A goat furnishes from two to three 
quarts of milk daily. The milk has a peculiar animal taste unless the goat 
is stall fed. 

DILUENTS OF COW'S MILK 

Boiled Water; Farinaceous Water; Whey. — When raw cow's milk is 
to be fed, the author prefers giving boiled water as a diluent up to three 
months. When sterilized or Pasteurized cow's milk is to be fed, the writer's 
experience is in accord with the teachings of A. Jacobi, who says: 

"The barley and oatmeal are the two substances I mostly employ, as 
their chemical constituents are nearly alike, with the exception of a large 



MILK DILUENTS 



117 



portion of fat in oatmeal, which is not found in barley. Barley water or 
thinned and sweetened oatmeal may be given to the child even at the breast. 
The indications for the use of one or other lie in the condition of the infant. 
Where there is a decided tendency to constipation, I prefer oatmeal; where 
there is no such tendency, as usual, or perhaps even a tendency of the bowels 
to be loose, I employ barley." 

If whole cereals are used instead of flour, two to four tablespoonfuls 
to a quart must be taken (with some salt), and cooked for one to two hours. 
An equal part of top milk is added to such a decoction and some cane 
sugar. (See article on Home Modification of Cow's Milk.) The mixture, 
when fed, should have a temperature of 80° to 90° F. Whey, deprived of 
its fat, has been suggested as a diluent of cow's milk. 

Dextrinized Gruels. — In exceptional and selected cases more satisfac- 
tory results are obtained if the gruel which is used to dilute or modify the 
cow's milk is dextrinized by means of malt diastase or cereo. 

Whey. — In case of inability to digest the casein of cow's milk, or an 
idiosyncrasy toward milk, the milk can be curdled with rennet or pepsin, 
and the curd removed. 

l 1 per cent of fat. 
Whey contains < 1 per cent of lactalbumin. 

f 4 per cent of sugar. 

In feeding with whey, sugar and cream must be added to make up for 
the deficiency of both in the whey. 

PRESCRIPTION BLANK FOR MILK FOOD 



Per Cent. 



Remarks. 



5 Fat 

Milk sugar . . . . 
Albuminoids . . . 
Mineral matter. 
Total solids .... 
Water 



100 



00 



Number of 

feedings 

Amount at 

each feeding 

Infant's age 

Infant's weight 

Alkalinity % 

Heat at °F 



Ordered for 



Date, 



Signature, 



118 



PEDIATRICS 



MILK LABORATORIES AND PRESCRIPTION WRITING FOR MILK FOOD 



Through the efforts of Dr. T. Rotch, of Boston, and the Walker-Gordon 
Company, milk laboratories have been established in our large cities in 
connection with model dairies. They furnish pure, clean milk and cream 
of full strength or modified. Milk food is delivered in 
f~\ bulk or in bottles containing a single feeding, according to 

the physician's order or prescription. The price for a 
day's rations of modified milk varies from 30 to 80 cents. 
Clean milk is delivered for 15 cents a quart. This plan has 
advanced the knowledge of infant feeding, has made it pos- 
sible for parents to obtain clean milk for their children, 
and is a great convenience in cases in which home modifi- 
cation of cow's milk cannot properly be carried out. 




Babcock Milk Tester 

Several methods of rapidly determining the amount of 
fat contained in milk with the aid of chemical reagents have 
been devised. One of the most accurate is the Babcock 
milk test. The little machine constructed to apply this 
test, of which several patterns are made, is in use in almost 
all well conducted milk receiving stations. It requires 
about a tablespoonful of milk for a sample, and the exact 
percentage of fat in it can be determined by this test in 
ten or fifteen minutes. The result is obtained by the 




Fig. 48. — Lactom- 
eter. 



Fig. 49, — Cream Testing Outfit. 



COW'S MILK FOR INFANT FEEDING 



119 



action of centrifugal force combined with some chemical effects. The 
original cost of the machine is from $3 to $15, according to size and pat- 
tern, and a few cents' worth of materials are used at each operation. Its 
manipulation is easily learned, and it can be successfully operated by any 
careful person by following the directions which come with the apparatus. 

COW'S MILK FOR INFANT FEEDING 

Our principal aim is to take the composition of mother's milk as a 
standard, and to adjust cow's milk in accordance with this standard, cow's 
milk being the most available substitute for mother's milk which we have. 





Fat. 


Sugar. 


Proteids. 


Human milk 


4.00 


7.00 


1.50 


Cow'6 milk 


4.00 


4.00 


4.00 



Modification of cow's milk is accomplished by reducing the proportion 
of proteids by dilution : by increasing the quantity of fat originally sufficient, 
but made insufficient in amount by the necessary dilution; by increasing 
the sugar and salt made insufficient in amount by the necessary dilution. 

The manipulations necessary to modify or adapt cow's milk for infants 
can be carried out in the household or in milk laboratories. The intro- 
duction of percentage feeding has placed infant dietetics on a scientific 
basis and has given us milk laboratories, but success in infant feeding is 
not a matter of accurate percentages — as the general practitioner has 
erroneously inferred. Milk food ordered by prescription according to the 
percentage method and supplied by the laboratory has given very excellent 
results, but we may obtain the same gratifying results by home modifica- 
tions, by simple dilutions, in which the principle of percentage feeding is 
carried out in a simple way. 

For various reasons modifications of cow's milk, whether done in the 
household or in the laboratory, will not give uniform good results in difficult 
feeding cases, no matter how accurate we are in our manipulation of per- 
centages. The chemistry of digestion is very complex, and the alimentary 
canal is not a test tube. The behavior of food in an infected intestine 
or feeble organism is often difficult to understand, and thus our best efforts 
will have their limitations. Success in feeding will not come to us with 
mathematical certainty. Minute differences in the composition of the 
proteids of cow's milk as compared with human milk have a theoretical 
but no practical interest. Suggestions for modifying cow's milk which 
take into consideration the minute differences in chemical composition 
are thrown to the winds. We cannot convert cow's milk into mother's 
milk, no matter how scientific we are. We are obliged to use cow's milk 
as Nature furnishes it, and without proper hygienic management neither home 
nor laboratory modification of cow's milk will fit the baby with a capricious 
digestion. With proper hygienic management, however, clean cow's milk, 
properly diluted or modified, will fit the vast majority of infants. 

In the home modification of cow's milk, the greatest simplicity is desir- 



120 



PEDIATRICS 



able for all concerned. Simple dilution of top milk with water or farinaceous 
water will answer in the vast majority of cases, if the deficiency of sugar 
and salt is made up by adding these substances to the diluted top milk. 

The following simple method of home modification has been practised 
by the writer for the past twenty years: If a quart bottle of average good 
milk stands four hours, the upper half of the milk will contain about twice 
as much fat as the milk before standing. This pint of so called top milk 
is decanted or dipped out by means of the Chapin dipper and forms the 
basis of bottle food for home modification. By diluting this pint of top 
milk in various proportions, viz.: 1-1, 1-2, 1-3, 1-4, 1-5, we obtain a food 
of various strengths as regards fat and proteids. The deficiency of salt and 
sugar is readily made up by the addition of these substances, and a food 
can thus be prepared which will vary in composition according to the 
requirements of the child to be fed. The cost of a daily feeding with the 
best milk obtainable is about twenty cents a day. 

When clean milk can be had, the milk may be given raw. In hot 
weather and with the average milk supply the food must be sterilized. As 
an additional precaution the top milk may be filtered through a layer of 
cotton in a funnel. 



SCHEDULE OF HOME MODIFICATION OF COW'S MILK 





No. 1 (1-4). 


No. 2 (1-3). 


No. 3 (1-2). 


No. 4 (1-1). 


Cane sugar 


2 ounces 


1 J ounces 


1} ounces 


1 ounce 


Table salt -. 


35 grains 


30 grains 


25 grains 


20 grains 


Diluent 


26 ounces 


24 ounces 


20 ounces 


15 ounces 


Top milk 


6 ounces 


8 ounces 


10 ounces 


15 ounces 



The diluent may be boiled water, oatmeal or barley water, or whey. 



No. 1. — For young infants (one month) and difficult feeding cases. 
Feed 1 to 2 oz. every two hours (twice at night). 

No. 2. — Adapted for young infants with good digestion or for infants 
two to three months old. Feed 2 to 3 oz. every two hours (twice at night). 

No. 3. — Adapted for infants of from four to eight months. Feed 4 to 6 
oz. every two and a half to three hours, eight feedings in twenty-four hours 
(once at night). 

After the eighth month give six bottles and two feedings of cornstarch 
pap with egg, or mutton or beef broth with rice or sago, tapioca, or pea soup. 

No. 4. — Rich milk adapted for children over one year old. Give five 
bottles, 6 to 8 oz. each, and two additional feedings as above mentioned. 

Pour the mixture into small nursing bottles, each to contain one feeding, 
and cork with a pledget of clean cotton- and sterilize in warm weather. 
Sterilized milk keeps without ice. Keep raw and Pasteurized milk food 
on ice. Before feeding, heat to the body temperature by placing the bottle 
in hot water. Then remove the cotton and feed by means of a rubber 
nipple. 

This method of modifying cow's milk does away with the addition of 
separated cream and is a distinct advantage over the so called cream mix- 



COW'S MILK FOR INFANT FEEDING 



121 



ture, because separated cream, having a high market value, is not invari- 
ably fresh, has not a uniform composition, and is very prone to spoil 
and give rise to dyspeptic diarrhoeas and symptoms of milk poisoning in 
general. 

Cow's milk modified in the household according to this simple method 
will agree with the vast majority of infants. In a difficult feeding case 
it is best to stop feeding milk for a few days and begin again with a low 
strength modified milk and gradually work up. When we encounter a 
positive idiosyncrasy for cow's milk we may be compelled to make use 
of some other foods. An idiosyncrasy for cow's milk in proper dilution 
should not be suspected until after the children have had proper hygienic 
management to help them digest their milk. 

Infants and children who are kept indoors in cool and cold weather, 
and breathe the air of overheated and stuffy living apartments, will not 




Chapin dipper. Fig. 51. — Seibert's Aluminum Milk- 

Fig. 50. Filter, with Cotton Disk. 



digest well, no matter what they feed on. It should be made a practice to 
send infants out of doors from the time that they are six weeks old. The 
insane fear of breathing cool fresh air is almost as pronounced to-day as 
it was in times before the advent of the germ theory of disease, and is re- 
sponsible for most of the indigestion among children. A move in the right 
direction as regards the hygienic management of infants and children has 
been started in Boston by some of the wealthy families in the Back Bay 
district, who put their babies to sleep in a box on the flat roof or on a 
balcony or window sill, summer and winter. The method is begun when 
the baby is two months old, and may be continued as long as the custom 
of having a daily nap is kept up. 

The baby is wrapped like an Indian papoose and strapped to the box 
or basket in such a way as to give freedom to the feet and arms and yet 
make it impossible for the child to crawl out. The crib is shielded from the 
wind and direct sun rays by an awning overhead. If the outdoor treatment 
is carried out, drugs and digestive ferments and the peptonizing process 
are hardly ever indicated. 



122 



PEDIATRICS 



To sum up, I would say that there are no universal rules for feeding 
cow's milk. What we must aim at is to individualize in each and every 
case, and not attempt to adapt one form of feeding to all cases and under 
all conditions. In a difficult feeding case cow's milk should be discontinued 
for a short time and cereal decoction and white of egg, etc., substituted. 
In resuming cow's milk we begin with a low strength and gradually work 
up to full strength milk and avoid overfeeding. Digestion of cow's milk 
is best stimulated by carrying children out of doors, not by drugging. 
Digestive ferments and peptonized milk are rarely indicated. 

Idiosyncrasy for cow's milk is managed by selecting some substitute 
food, if possible the breast of a wet nurse. In some cases whey with cream 
and cereal decoction will fit the baby. The whey proteids differ as to 
digestibility from the casein. 

Cow's milk should be sterilized (steamed) in warm weather. The pres- 
ervation of cow's milk by means of a harmless chemical is a desideratum ; 
because the heating process slightly alters the digestibility of cow's milk. 
Behring has suggested the use of formaldehyde for preparing a permanent 
milk (1 to 10,000). Infants will usually thrive on properly modified cow's 
milk up to seven months. After the seventh or eighth month they are apt 
to become rhachitic unless they receive beef or mutton broth, with cereals 
and egg, in addition to cow's milk. With proper hygienic management 
to stimulate the motor function of the gastroenteric tract, we may let the 
secretions take care of themselves. 

How to Feed. — Select round, wide mouthed, graduated nursing bottle, 
and use black rubber nipples. Hold the bottle upside down and see that 
the hole in the nipple is large enough to allow the food to drop slowly, not 
run in a stream. Heat the food by placing the bottle in warm water for 
a few minutes, or heat the contents of the bottle in a dipper over a fire 
and return to the same bottle. Shake the bottle before feeding. Never 
warm any food that may be left in the bottle. Throw it away. Never 
give anything but cool water that has been boiled, between meals. As 
a rule, children do not get enough water. 

Care of Nursing Bottles. — After feeding, rinse the bottle with cold water, 
and then wash with hot solution of borax (one teaspoonful to a quart) 
and a bottle brush. When the bottle is not in use, keep it full of water and 
the nipple lying in water in which a little borax has been dissolved. Before 
using the bottles, scald them with boiling water. 

Raw milk should be fed only during the cold months. As soon as warm 
weather sets in the bottle food (milk food) must be sterilized or Pasteurized. 

Strength of Milk Food. — In ordering milk for an infant, not only its age 
but its weight must be taken into account. There are some cases where 
the strength of the milk food may be increased rapidly. Usually it is 
best to begin with low strength milk food and gradually increase as the 
child gets older and heavier. The critical time in infant feeding is the first 
two months, and the difficult feeding cases are those in which infants have 
made a bad start. 

It must be distinctly understood that there are no set formulae for the 
various ages and weights of infants. The digestive capacity for food and 
food components — fats, proteids, and cereals — is different in various in- 



COW'S MILK FOR INFANT FEEDING 



123 



dividuals and at various periods. It is lessened in hot weather and illness, 
and increased in cold weather. A steady increase in weight and the appear- 
ance of two gamboge yellow stools a day are the best indications of good 
feeding. The strength of the food may be modified once a month to suit 
the condition of the child. 



TABLE FOR THE FEEDING OF THE HEALTHY INFANT DURING THE FIRST YEAR 



Ages. 


Number of 
feedings within 
24 hours. 


Quantity for each feeding. 


Fat. 


Percentages 
Sugar of milk. 


OF 

Proteids. 


l6t week 


10 


1-1 oz. 15- 30 cc 


2 




5. 





50 




2d week 


10 


1 -11 oz. 30- 45 cc 


2 


25 


5-6 





50-0 


75 


3d-4th week 


10-9 


lf-2 oz. 45- 60 cc 


2 


50 


6. 





75-0 


90 


4th-6th week 


9-8 


2 -2J oz. 60- 75 cc 


3 




6-6.50 





90-1 




6th-8th week 


9-8 


21-3 oz. 75- 90 cc 


3 




6.50 


1 


00-1 


25 


3d month 


8 


3-4 oz. 90-120 cc 


3 




7. 


1 


25-1 


50 


4th month 


8-7 


4-5 oz. 120-150 cc 


3 


50 


7. 


1 


50-1 


75 


5th month 


8-7 


5-6 oz. 150-180 cc 


3 


50 


7. 


1 


75 




6th-7th month 


7 


6-7 oz. 180-210 cc 


4 




7. 


1 


75-2 




8th-9th month 


7-6 


7-8 oz. 210-240 cc 


4 




7-6 


2 


00-2 


50 


10th-12th month 


7-6 


8 oz. 240 cc 


4 




5. 


2 


50-3 


50 



Indications for Varying the Percentage of Fat, Sugar, and Proteids for 
Healthy Infants. — The exact indications for varying the percentage of fat, 
sugar, and proteids in cow's milk cannot be given in the present state of 
our knowledge. An excess of sugar usually gives colic, thin, green, acid 
stools, causing eructation of gas from the stomach and some regurgitation 
and frequent passages of nearly normal appearance; in some cases round 
masses of fat are passed. Too little fat shows constipation and dry hard 
stools (also observed in children who get sufficient fat). The writer has rarely 
ordered milk food with more than 4 per cent of fat. 

An indication of excess in proteids, or imperfect digestion of proteids, 
are the curds in the stool and colic, sometimes with constipation or diarrhoea 
or vomiting and regurgitation. Imperfect digestion of proteids or fat from 
lack of fresh air, from keeping children in overheated, close rooms, causes 
nearly the same symptoms as indigestion from other causes. It is therefore 
unwise to modify the milk so as to meet every temporary symptom of dis- 
comfort in the infant, but we should try the fresh air plan first, then reduce 
amount of feeding and finally modify the milk or food. If the symptoms 
persist, it will be necessary to cleanse the gastroenteric tract by means 
of a dose of oil, rhubarb and soda, or calomel, and give farinaceous water 
and white of egg for a few days and then return to a bottle food of less 
strength, which is more apt to be digested. For infants who are unable to 
assimilate the milk dilutions here recommended it is best to procure a wet 
nurse without much loss of time. The management of difficult feeding 
cases is discussed elsewhere. Premature infants, if deprived of breast 
milk, are fed on low strength food by means of a medicine dropper. They 
take from a drachm to an ounce about every two hours, and should be 
fed slowly. 



124 



PEDIATRICS 



DIET FOR CHILDREN AFTER WEANING OR DURING THE SECOND YEAR 
OF BOTTLE FEEDING AND AFTER THREE YEARS 

Milk. — Full or of half strength — sterilized or Pasteurized in summer. 

Cereals. — Oatmeal, farina, hominy, etc., well cooked. Cracked oats, 
cream of wheat, Pettijohn, rice, force, with salt, sugar, or cinnamon, with 
and without fresh cream or top milk. 

Toast, milk toast, zwieback, crackers, sweet crackers, bread and butter. 

Meat broth, soups with cereals, with egg, with toast; eggs, scrambled, 
custard. After eighteen months give minced meat. Water boiled and 
cooled. 

Diet for Children from Two to Three Years Old. — Add mutton chops, 
rare beef, soft boiled eggs, baked apples, stewed prunes, and orange juice, 
Diet after Three Years. — 

Soups. — Plain soups and broths of nearly any kind. 
Eggs. — In any form, soft boiled, omelette, scrambled, poached, or beaten 
in milk. 

Meats. — Beef, beefsteak, lamb, mutton, lamb chops, chicken, and turkey, 
broiled, roasted, or boiled. 

Fish. — Any kind, boiled or broiled. 

Vegetables. — Peas, beans, spinach, lettuce, potatoes, tomatoes, as- 
paragus tips, stewed celery. 

Cereals. — Oatmeal, rice, hominy, wheat, barley, corn meal, wheat and 
graham bread, toast, zwieback, oatmeal, soda and water crackers, maca- 
roni, etc. 

Fruits. — Nearly all stewed or sweetened, peaches, pears, plums, oranges. 

Dessert. — Light puddings, custards, jellies, ice cream, honey, chocolate. 
(Most of the jams in the shops are artificial or adulterated.) 

Young children should be fed five times a day; they usually take from 
two to three pints of fluid food; some children will be hungry at all times 
and others have a capricious appetite. The nibbling of food between meals 
destroys the appetite. No food will agree unless the children exercise. 
The craving of children for sweets should not be entirely ignored. School 
children should have a short vacation at reasonable intervals or as soon as 
they show marked fatigue. Children's digestion suffers but little from 
romping after a meal. 

DISORDERS OF THE DIGESTIVE TRACT 

GENERAL REMARKS 

This group of ailments is intimately connected with the various problems 
in infant feeding and oral and general hygiene. A clear understanding of 
such a relationship is a valuable accomplishment in the family practitioner. 
To look upon acute inflammatory diarrhoea as due to bacterial invasion 
and largely preventable marks a great advance in pediatric practice as com- 
pared with our former views on the aetiology of diarrhceal disorders, which 
centred in worms, teething, and "catching cold." To make a physiological 
process like dentition responsible for innumerable ills and sins is certainly 



DISORDERS OF THE DIGESTIVE TRACT 



125 



convenient and about as rational as to assume that the growth of hair or 
nails bears a causal relation to parasitic and other skin disease. 

Admitting that teething in some infants may cause pain, it is best to 
ignore dentition as an aetiological factor in sickness, and thus attempt to 
eradicate a popular superstition which has at all times worked untold harm. 
Let it be understood by mothers and nurses that the second summer diar- 
rhoeas have a causal relation to a change in feeding or to faulty feeding, not 
to dentition, and that the treatment is dietetic and hygienic, not medicinal. 
Cases of primary inanition from too little food (such as scanty breast milk) 
are not apt to occur in bottle fed children. On the other hand, indigestion 
and dyspepsia or fermentative diarrhoea are not rare in breast fed infants 
from overfeeding or poor breast milk. In bottle fed children, however, 
and particularly in hot weather, diarrhceal disease is an every day occurrence. 

Spoilt food, overfeeding, faulty hygiene, and weak digestive powers 
are provocative of indigestion, and lead to temporary or prolonged malnu- 
trition. The so called difficult feeding cases frequently develop into in- 
flammatory diarrhoeas of severe type or lead to the various forms of mal- 
nutrition and intestinal toxaemia, such as atrophy, rhachitis, and scurvy. 
From the mild to the severe forms we have one chain of pathological con- 
ditions. Thus the timely treatment of a mild form of diarrhoea may 
prevent a dangerous cholera infantum, etc. 

After indigestion has persisted for a time, atony and dilation of the 
stomach result. In the more active inflammatory diarrhoeas structural 
changes in the intestinal mucosa are found, and frequently grave complica- 
tions follow such structural changes. 

Renal Complications of Acute Enteric Disorders. — Degenerative changes 
in the kidneys occur in many cases of prolonged intestinal indigestion and 
inflammatory diarrhoeas, due to the action of bacteria and toxines. In 
such cases albumin and renal elements are found in the urine. When found 
in cases of infantile atrophy they are of grave prognostic import. 

Regarding the nomenclature of gastrointestinal disorders, it may be 
remarked that in the present state of our knowledge a purely anatomical 
or purely microbial nomenclature of diarrhceal diseases is impossible. A 
simple diarrhoea may be of nervous or psychic origin or may be due to over- 
feeding and food fermentation, during which substances are formed which 
have a laxative action or a toxic action (milk poisoning) , or diarrhoea may 
be symptomatic, as in the course of infectious and organic disease. The 
catarrhal or inflammatory diarrhoeas are all due to microbial invasion of the 
intestine itself. Acute gastroenteritis and enterocolitis in children are 
evidence of such local infection. The mild forms may terminate in severe 
forms. The Bacillus dysenteric described by Shiga in 1898 seems to bear 
some aetiological relation to the diarrhoeas of infancy, and has been found in 
the mild inflammatory forms as well as in the severe forms in breast fed 
and bottle fed children. The results of the treatment with antidysenteric 
serum have so far been disappointing. All inflammatory diarrhoeas are 
communicable. The hand that attends to the toilet of a sick child should 
not feed the well children. 



126 



PEDIATRICS 



AILMENTS OF THE MOUTH IN CHILDREN 

Slobbering of Infants. — This manifestation, which is aptly enough de- 
scribed by the name accorded it, is not of infrequent occurrence in early 
infancy and during the period of active dentition. Though frequently 
ascribed to local irritation, difficult dentition, and uncleanliness, it is not 
necessarily so caused, and is often met with in idiots, epileptics, and the 
morally and physically degenerate. 

Bleeding of the Gums. — Independently of the acute inflammatory affec- 
tions of the gums, bleeding is observed in scurvy. (See Scurvy.) When the 
bleeding does not respond to simple methods, prolonged pressure over the 
bleeding spot with a pledget of cotton saturated with alum solution, or a 
10 per cent antipyrine solution or adrenalin solution, or the actual cautery 
may be applied. 

Stomatitis Catarrhalis. — This form of inflammation is usually of a mild 
type, runs an acute course terminating in about a week, and is not associated 
with pronounced constitutional symptoms. It is generally observed during 
infancy and is caused by the introduction of irritating and unclean sub- 
stances into the mouth (e. g., dirty fingers, unclean nipples). It may be con- 
comitant with or secondary to the exanthemata and to gastrointestinal 
affections. The symptoms are mild. There is some rise in temperature; 
the mouth at first is red, dry, and hot. Thirst, pain, and irritability are 
present. Later the mouth becomes moist and there is increased saliva- 
tion. The changes in the mucous membrane consist simply of local 
hyperaimia, increased epithelial proliferation, and subsequent desquama- 
tion with little or no tendency to ulceration. 

The treatment of this affection consists in keeping the mouth clean 
with a 2 per cent boric acid solution or a mild solution of borax in water 
and glycerin. Should constipation exist, a mild laxatixe may be given. 

Stomatitis Follicularis (Aphthous, or Vesicular, Form). — This is of 
severer type and longer duration than the simple catarrhal form. The local 
tissue changes are more marked and the constitutional disturbance is more 
pronounced. Causative agents are any of the severer constitutional dis- 
deteriorated state of health, malnutrition, and unhygienic conditions 
and surroundings. The change observed in the mucous membrane con- 
sists in the appearance of vesicles which ulcerate and have swollen, well 
defined, grayish yellow denuded surfaces. The affection is in many instances 
so painful that the child refuses nourishment. 

Treatment. — A pale rose colored solution of potassium permanganate 
or boric acid, 6 parts; salicylic acid, 1 part; water, 500 parts, or alum 
water (a teaspoonful to the pint), should be used as a mouth wash and gargle. 
The mouth may be swabbed frequently with cotton pledgets moistened 
with one of the solutions. Other agents which may be employed are: 

Tannic acid, 5i ) on j • *. t l 

. b - r 30 drops to a pint ot water. 

Glycerin, 5j ) 

Or Labarraque's solution in water, 1 part to 20. 

Croupous or Membranous Stomatitis. — Abrasions, wounds, and inflamma- 
tory lesions in the mouth or nasopharynx are frequently found to be covered 



AILMENTS OF THE MOUTH IN CHILDREN 



127 



with a yellow pseudomembrane, which may be diphtheritic or non-diphthe- 
ritic. This occurs frequently as a complication of the eruptive fevers and 
whooping cough and following operations in the mouth or on the tonsils. 
From the mouth it may spread to the nasopharynx and larynx. When it 
invades the latter, it may manifest itself as membranous croup, and in this 
respect the significance of membranous stomatitis is underestimated in 
general practice. A culture from the mouth will reveal the presence or 
absence of diphtheria bacilli. When they are present, 1,000 to 2,000 units 
of antitoxine should be injected in the usual way in order to prevent 
further systemic infection. The local treatment is the same as for ordinary 
forms of stomatitis. 

Thrush, or Muguet, frequently termed Sprue (Mycetogenetic Stomatitis), 
is a form of stomatitis caused by the organism termed Oidium Albicans. 
On the tongue or buccal mucosa numerous small white pellicles appear, 
frequently coalescing and invading the epithelial and mucous surfaces. 
The disease is of very frequent occurrence in young infants and is probably 
caused by local uncleanliness. Soiled nipples, dirty stoppers and bottles, 
and dirty clothes are agents which carry the infection to the mouth. Poorly 
nourished and delicate children are the frequent subjects of thrush. Its 
distinguishing features are the small white flakes resembling coagulated 
milk. On attempting to forcibly swab these particles away, small bleeding 
points appear at their site. Microscopical examination of the deposit 
shows the organism. 

Treatment. — The mouth should be gently wiped out with a borax 
or bicarbonate of sodium solution before and after each feeding, and every- 
thing that is carried into the mouth should be clean. 

Tongue tie is due to a short frenum, and in consequence protrusion of 
the tongue is interfered with, sucking is embarrassed, and the condition 
if not remedied, will eventually interfere with distinct articulation. To 
remedy the deformity, the frenum is " nitched " with small scissors in a 
direction downward and backward to avoid the ranine artery, which lies 
in the fold of the frenum, running up along the base of the tongue. 

Tongue Swallowing. — Asphyxia from swallowing the tongue, owing to 
its riding over and shutting off the opening of the glottis, is occasionally 
observed. The tongue is drawn back and down over the glottis by the 
muscles of deglutition, and this is due to congenitally long or large tongue 
or lax frenum. This condition calls for immediate relief. The tip of the 
tongue may be caught up by the finger, forceps, or suture and drawn for- 
ward whenever the danger of asphyxia threatens. 

Strawberry Tongue. — This name is given to a bright red appearance of 
the anterior part of the tongue with the filiform papillae glistening through 
the mucous lingual surface. This condition is typical of scarlet fever in 
the early stage of the disease. 

Geographic Tongue. — This is occasioned by local desquamation of the 
lingual epithelium in patches. The bases of the patches are red and of 
irregular maplike shape, hence the term geographic. This condition is of 
parasitic origin and may last for months. Special treatment is unnecessary. 

Dental Ulceration (Riga's Disease). — The presence of carious teeth in 
the mouth and prolonged friction of the tongue or frenum against the teeth 



128 



PAEDIATRICS 



are causes. As a rule, touching the base of the ulcer a few times with a 5 
per cent nitrate of silver solution suffices to cure. Decayed teeth should 
be extracted or filled. 

Sublingual Ulcer. — This is frequently met with in children suffering from 
whooping cough; the ulcer presents itself where the frenum is in contact 
with the incisor teeth. 

The treatment resolves itself into cleansing the ulcer and occasionally 
touching it with lunar caustic to encourage healthy granulation and repair. 

Sublingual Granulation Tumor. — This may be removed by scissors or 
scraped away with a spoon or cauterized with lunar caustic. The mouth 
must be kept clean by means of mild antiseptic solutions. 

Herpes of the Lips. — Herpes blisters develop on the lips in the course of 
febrile disease. Camphor ice acts admirably as a soothing application. 

Perlesche starts at the angle of the mouth as a small fissure and spreads 
as an ulcer covered with a grayish exudate. 

The treatment is cleanliness, cauterization with nitrate of silver, and 
protecting with camphor ice. 

Cracks and Fissures of the Lips. — This condition requires stretching of 
the lip and the application of nitrate of silver and camphor ice. 

Eczema of the lips yields to mild protecting ointments. 

Sordes. — A brown coating of the lips in febrile disease. The treatment 
consists in washing and applying camphor ice. 

Protruding Tongue of Cretins. — (See Cretins.) All other conditions of 
the mouth and tongue are discussed in the chapter on Diseases of the 
Mouth. 

MUMPS; PAROTITIS 

An infection of the parotid or other salivary glands, characterized by 
a swelling of the gland or glands and mild constitutional symptoms. In- 
fants are rarely afflicted; most cases occur in children between three and 
fourteen. 

The epidemic parotitis is contagious and therefore of microbial origin. 
The contagium has not been isolated. The portal of entrance is probably 
the buccal cavity; therefore hygiene of the mouth is the best preventive. 
Three weeks after the termination of a case the danger of infecting others 
is probably over. 

Symptoms and Differential Diagnosis. — Malaise, fever (101° to 103°), 
headache, vomiting, pain in the angle of the jaw, localized swelling on one 
or both sides, a disagreeable pressure sensation, and dryness. Chewing and 
speaking are painful and difficult. The swelling disappears after from eight 
to ten days. 

Mumps may be confounded with acute swelling of the central lymph 
nodes. In mumps the lobe of the ear is near the centre of the enlargement. 
The enlarged lymph nodes are behind the ear and behind the jaw, never 
upon the face. The swollen neck, as observed in some cases of tonsillitis, 
diphtheria, or scarlatina or measles with throat complications, should not 
been mistaken for mumps. On the other hand, inflammation and suppura- 
tion of the parotid gland may complicate an infectious disease, as in typhoid 
fever and various forms of sepsis and by extension in otitis media. 



INDIGESTION AND DIARRHEAL DISORDERS 



129 



Treatment. — Unless the symptoms are severe, the patient may be up 
and about in fresh air. The diet should be restricted and the bowels opened 
by from three to five grains each of calomel and jalap. The nasopharyngeal 
toilet with salt water should be employed, and antiseptic gargles and 
mouth washes are indicated. If the symptoms are severe, the patient 
is put to bed on fever diet. Ichthyol vaseline (3 per cent) or camphorated 
oil may be gently rubbed over the painful swelling, and an ice bag or hot 
water bag may be applied. A sympathetic swelling of the other glan- 
dular organs (orchitis, mastitis, ophoritis) and of the joints usually subsides 
with the parotitis. Otitis media and deafness, and meningitis by ex- 
tension, are rare sequela?. In suppuration of the gland incision and drain- 
age are indicated. Prognosis is favorable. 

INDIGESTION AND DIARRHCEAL DISORDERS 

HABITUAL CONSTIPATION AND DIFFICULTIES OF DEFECATION 

IN INFANTS 

Straining at stool and constipation are found in infants principally under 
the following conditions: Weak peristalsis from lack of muscular develop- 
ment in the rectum and difficulty of overcoming resistance at the rectal 
valve, as in congenital and acquired rickets; low percentage of fat and of 
total solids in the food; fissures at the anus, giving pain in defalcation: 
chronic intestinal indigestion with constipation and "putty stools "; opium 
preparations given secretly to quiet the child. 

A weak peristalsis will ultimately be overcome by the process of develop- 
ment, and forcible dilatation of the sphincter is readily performed. Fis- 
sures require dilatation of the sphincter and cauterization with a 2 per cent 
nitrate of silver solution. 

Aside from the selection of the proper diet in rhachitic infants we may 
aid nature in overcoming constipation by increasing the fat and solids 
in the food; administering fruit juices (prune juice) and Vichy water or 
sulphate of sodium (10 grs.) ; administering soap suds enemata or soap 
suppositories; gentle massage of the abdomen and vibratory massage; 
keeping children out of doors all day. (See also general article on 
Constipation.) 

COLIC AND VOMITING 

Colic. — The distention due to the formation of gases in the intestines 
is probably the cause of pain. Bottle fed children are very apt to suffer 
from this condition, which is a strong indication for reducing the strength 
of the food. An attack of colic is treated by giving a warm soap suds enema, 
a warm bath of 95° F., and warm fennel or mint tea to drink. Opium is 
rarely necessary. The relief which follows these measures will enable the 
physician to exclude intestinal obstruction or appendicitis. It should be 
borne in mind that small umbilical hernias are sometimes responsible for 
recurring attacks of colic, also renal gravel. 

Simple Vomiting. — Frequent vomiting is a very annoying symptom, 
and food is rejected very soon after it is taken into the stomach. Should 
10 



130 



PEDIATRICS 



fresh air treatment and a reduction of the food strength not give satisfactory 
results the following prescription may be offered: 

R^ Tinct. iodini, gtt. x; 

Aq. menth. pip., 5vj; 

Syrupi sacchari, 3ij- 

M. et signa: A teaspoonful every hour or two. 

Habitual vomiting may often be overcome if the children are fed by 
gavage. (See General Therapeutics.) Persistent vomiting and rapid ema- 
ciation in the new-born are suggestive of pyloric stenosis. 

Recurrent Vomiting; Cyclic Vomiting. — Obstinate and repeated vom- 
iting is the most striking symptom, coupled with thirst, a bad odor from 
the mouth, emaciation, and exhaustion. The attack may last from one 
half to fourteen days and is looked upon as a toxic neurosis. A differ- 
ential diagnosis must be made between periodic vomiting, vomiting in acute 
infectious disease, in acute indigestion, in intestinal obstruction, and in 
meningitis. 

Recurrent vomiting is autotoxic in origin and characterized by repeated 
attacks of nausea, persistent vomiting, and great prostration. The great 
majority of cases occur during infancy and childhood. Heredity is the 
most important predisposing factor. A general neurotic inheritance is 
common. Nearly all of these patients are constipated, and this condition 
is doubtless an important setiological factor. Overeating is a very potent 
factor. Warning symptoms are flushings of the cheek, coryza, general 
restlessness, nervous irritability, sleeplessness, sallowness of the complexion, 
dark rings under the eyes, general malaise, constipation, and loss of appetite. 
Vomiting follows the prodromes in from six to forty-eight hours. After an 
attack the stomach, as a rule, resumes its functions. Thirst is a striking 
symptom. Emaciation is extreme in long continued cases. Gastric pain is 
not present in these attacks in children. Nervousness is very marked. The 
urine is very concentrated. The prognosis in relation to recovery is good. 

Treatment op Recurrent Vomiting. — The sources of reflex irrita- 
tion should be sought for and removed, if possible. 

Diet. — Reduction of food strength. 

Fresh Air. — Six to eight hours out of doors daily. 

Enteroclysis. — Daily. (See General Therapeutics.) 

Tincture of iodine internally in drop doses every hour in sugar water 
during the attack. 

Stomach washing in severe cases. In the interval apply hydrotherapeutic 
measures and abdominal massage. 

ACUTE INDIGESTION 

Mild Form Acute Dyspepsia, Gastricismus. — This is due to dietetic 
imprudence, overfeeding at the breast or by the bottle, and unsuitable, 
irritating, or decomposing food. 

Symptoms. — Eructation, nausea, vomiting, coated tongue, loss of 
appetite, thirst, usually no fever. There may be constipation or diarrhoea 
and evidence of dull pain. 



ACUTE INDIGESTION IN INFANTS 



131 



Principles of Treatment. — Relieve the gastroenteric tract; restrict 
food (no food for six to twelve hours) ; quench thirst by giving water or 
tea or toast water; give cool sponge baths in warm weather; carry the 
child into the open air. 

If vomiting and diarrhoea coexist, the stomach and intestine will soon 
be relieved. If not, advise a dose of castor oil or calomel (six half grain 
doses with sugar should be given every half hour) and plenty of boiled cool 
water or toast water to quench thirst. If the tongue remains coated twenty- 
four hours after the bowels have moved, the following prescription will aid 
digestion and may be given to children over one year old: 



A teaspoonful after feeding. 
A dyspeptic attack requires no other medication. 

Milk should not be given for a day or two; farinaceous or mucilaginous 
drinks may be given instead. 

Substitute diet in Indigestion and Diarrhoea when milk is contra- 
indicated : 



As soon as the dyspeptic symptoms have ceased, we return to breast 
feeding (if not otherwise contraindicated) or to the proper bottle food, 
with a caution not to overfeed. 



Severe Type. — Infants at the breast or on the bottle frequently be- 
come acutely ill with high fever (105° to 106°), rapid pulse and rapid 
breathing, great unrest, twitching or convulsions, and vomiting with and 
without diarrhoea. These symptoms are sometimes quite alarming, and 
are due to acute milk 'poisoning with gastric irritation. They very much 
resemble the sudden onset of other acute infectious diseases. In the 
absence of throat symptoms and meningeal symptoms, the true nature of the 
onset will be recognized by the experienced practitioner. 

Management. — Stop feeding milk; give farinaceous drinks only; give 
a warm bath (95° F.) ; give a warm soap suds enema. In the way of medi- 
cation, four to six half grain doses of calomel may be given, one every hour. 
The temperature usually drops to the normal in twelve to twenty-four 
hours, after which it will be safe to give the breast at proper intervals. 

Bottle fed babies should receive, for a week, diluted cow's milk of less 
strength than before the attack, according to the directions given in the 



R- Acid, hydrochloric, dil 
Ess. pepsin., 



gtt. x; 
5j. 



Young Infants. 
Oatmeal water. 
Barley water. 
Rice water. 
Gum arabic water. 
Peppermint tea. 
Toast water. 
White of egg and water. 



Older Children. 
Cornstarch pap. 
Burnt flour soup. 
Farina. 
Beef broth. 
Mutton broth. 
Bouillon and egg. 



ACUTE CATARRHAL GASTRITIS IN INFANTS 



132 



PAEDIATRICS 



chapter on the Home Modification of Milk. In warm weather this milk 
should be sterilized. If the tongue remains coated, children over a year old 
may take two drops of dilute hydrochloric acid in essence of pepsin 
twice daily; and children of all ages must be kept in the open air as long 
as possible, or may be taken on a boat to derive the benefit afforded 
by the sea air. 

DIFFICULT FEEDING CASES IN BOTTLE FED INFANTS 
(PROLONGED INDIGESTION) 

Here we have to deal with children who have not been properly fed 
for weeks and months, or perhaps not since birth. All kinds of food have 
been given in succession, with or without drugs in addition. 

Symptoms. — Regurgitation, vomiting, colic; diarrhoea or constipation; 
incessant crying, no sleep, loss of weight; green stools with curds and some 
mucus. The children appear to be hungry. They become rhachitic or 
show evidence of scurvy, or they have slight general oedema, but are not 
yet in a condition of marasmus. The urine is free and there is no hypostatic 
congestion of the lungs. 

Treatment. — Medication is hardly ever indicated in cases of this nature. 
If the infant is not over three to four months old, the question of a wet 
nurse must be decided at once. If artificial feeding is to be continued, it 
will be best in some cases to wash the stomach and bowels once or twice 
with boiled water. (See chapter on General Therapeutics.) After thus 
cleansing the gastroenteric tract, feed from the list given under the heading 
of substitute diet. Give no milk for the time being. Have the child 
taken out of doors from four to six hours or into the country or on water 
trips. Also give a warm bath or a cool sponge bath in warm weather. 

Next in importance to the selection of proper food comes the hygienic 
management of the infant. A child should be constantly in the open air 
and out of the sun. It is also good practice to cleanse the mouth with a 
boric acid solution before nursing or feeding, particularly in the summer, 
for even germ-free breast milk or sterile cow's milk may become contami- 
nated by the bacteria residing in the oral cavity and thus infect the entire 
gastroenteric tract. 

Irrigation of the stomach and bowels may have to be repeated daily 
or every other day for a week or ten days. In extreme cases, when children 
get no rest day or night, we may allow them one dose of paregoric at night, 
ten to thirty drops, or a teaspoonful of the following mixture, also at night: 



It is not wise to resume milk feeding as soon as improvement is notice- 
able; it is better to wait a week or more. Then feel your way with low 
strength raw top milk (1 to 4) or sterilized top milk (1 to 4) in summer, 
or with white of egg and top milk, and discontinue irrigation as soon as 
possible. 



R- Chloral hydrate, \ _ _ 
Potass, bromid., \ 
Aq. cinnam., 

Ft. solut. 



5j. 



gr. x; 



CHRONIC INDIGESTION IN OLDER CHILDREN 



133 



TOP MILK AND WHITE OF EGG 



1$ Water, 



one pint and a half; 
one half pint; 
13 drachms; 



Top milk, . . . 

Sugar, 

White of egg 



one. 



Sometimes whey with or without cream is tolerated best. Under certain 
circumstances diluted condensed milk (1 to 12) with evaporated cream 
added will be tolerated and digested, or some proprietary food may be tried. 

In cold weather and in private practice, when it is possible to see a 
child at least every other day, it usually takes, on an average, two weeks of 
well directed effort to put the child on a proper feeding basis. No universal 
rule can be formulated which will insure success in the management of 
this class of cases. The physician must learn to individualize and feed in 
each particular case on its merits. If, after a reasonable trial with milk 
in various dilutions (during which time the children are to be out of doors 
all day, even in cold weather), a milk idiosyncrasy is evident, we must give 
up cow's milk feeding and nourish with food from the following : Meat broths 
and cereal decoctions with and without yolk of egg; gum arabic solution; 
white of egg in water; burnt flour gruel; cornstarch pap with egg. 



The class of cases to be considered under this heading includes those of 
children who are off the bottle from two years up, also school children with 
chronic dyspepsia. They are pale, sallow, yellowish, and flabby, and have 
no ambition or appetite. Some are constipated, others have liquid, offensive 
stools, or gray, pasty stools. The tongue is coated, the breath is offensive, 
and they are subject to follicular stomatitis, have bad teeth, and are ex- 
tremely nervous and irritable, particularly if they have a nervous mother. 
They grind their teeth in their sleep. A neurotic suppression of urine is 
occasionally observed and attacks of constipation lasting 2 week may set 
in with stupor, slow, irregular pulse, simulating intestinal obstruction or 
even meningitis, and many other phenomena due to intestinal toxaemia 
are observed. The temperature during such an attack is seldom above 
102°, often normal or subnormal; the urine is brown from indican. 

Associated with chronic indigestion we frequently find enuresis, reflex 
cough (adenoids), night and day terrors, vulvovaginal discharges, etc. 

In all such cases a careful clinical examination is called for in order to get 
at the underlying cause of the trouble and be able to manage the case intelli- 
gently. This may involve a regional, blood, urine, and stool examination. 

Etiology. — The underlying cause may be syphilis, tuberculosis, malaria, 
malignant disease, rhachitis, scurvy, diabetes, renal disease, hepatic dis- 
ease, cardiac disease, or pulmonary disease, central nervous disease, atony 
of the stomach, constipation, faulty diet (indulgence in candy, nuts, soft 
drinks), constant swallowing of pus from chronic nasopharyngeal catarrh, 
adenoids, etc. 

Neurotic parents are often responsible for the indisposition of the 
children by reason of keeping them indoors or in overheated rooms for fear 



CHRONIC INDIGESTION IN OLDER CHILDREN 



134 



PEDIATRICS 



of their "catching cold." The extreme of mismanagement was observed 
by the writer in a neurotic family as follows: The mother, with the aid of 
an accommodating medical talent, had a padded box stall constructed, five 
feet square and four feet high, closed on four sides. This was placed in 
the middle of the nursery and the little "two year old " was kept in close 
confinement during the day in this box in custody of a trained nurse for 
seven months of the year, in order to prevent colds and cough, to which 
the child was subject. On careful examination this tendency to "catch 
cold " was found to be due to adenoid vegetations in the nasopharynx. 

When the mother of a suffering child is not open to reason and the father 
is lucid, the physician should enlist the services of a nurse with diplomacy 
to manage the child properly, keeping the mother at bay. When both 
parents are dense, the case is almost hopeless, and the medical attendant 
will have to worry along or shift the responsibility to other shoulders. 

Treatment. — The treatment of cases of chronic dyspepsia in older chil- 
dren involves, therefore, in addition to the dietetic management, a study 
of the underlying cause and special treatment directed against the same. 
Furthermore, we must seek to establish regular habits in the child and 
reduce the neurotic tendencies by a daily sponge bath. 

The sleeping room should be cool and the living room not above 70° F. 
The child should be in the open air all day in fair weather and only come 
in for its meals. A change of climate is important in severe cases. The 
bowels should be made to move once a day, and massage of the abdomen 
or whole body should be performed daily. Older children should be sent 
to a gymnasium, and occasionally kept from school for a week or two when 
they appear fatigued or overworked. Gavage and stomach washing have 
their unpleasant features in older children with teeth, and will not as a rule 
be necessary. To aid digestion and overcome intestinal putrefaction, give 



Ichthyol in emulsion, in one or two drop doses twice a day, has given 
good results in some cases. A plain diet adapted to the age and condition 
of the child should be ordered. Cabbage, beans, raw fruit, spoilt milk 
or cream, ice cream, sweets, soda water, etc., are forbidden. Maltine and 
cascara may be given to keep the bowels open, also enemata. The under- 
lying cause must be treated. Give iron, phosphorus, arsenic for anaemia, 
quinine for chronic malarial disease (two to five grains every other day in 
a teaspoonful of compound elixir of taraxacum). 



The term summer diarrhoea may be applied to this form, but should 
not be used in connection with gastroenteritis, which is always catarrhal 
or inflammatory. The danger of a simple diarrhoea in summer lies in the 
fact that it paves the way for severe inflammatory diarrhoeas, and its timely 



ly Acid, hydrochloric, dil., 

Ess. pepsin., 

Tinct. quassia?, 

M. S : A teaspoonful three times a day. 



5j; 

5ij; 

5j. 



ACUTE FORMS OF DIARRHCEA 



Dyspeptic Diarrhcca ; Simple Diarrhaa 



SEVERE ACUTE FORMS OF DIARRHOEA 



135 



treatment prevents dangerous disease. Simple diarrhoeas are usually of 
nervous or dyspeptic origin. 

Prophylaxis. — Diarrhoeas can generally be prevented if the bottle food is 
sterilized before the warm weather sets in. 

Treatment. — First remove the cause. Undigested food must be removed 
by administering a laxative, such as castor oil (one to two teaspoonfuls). 
In addition, the colon may be flushed. Calomel may be administered in 
half grain doses every hour until six are taken. The milk food, breast or 
bottle, must be stopped at once, and slimy gruel of barley or oatmeal, gum 
arabic water, white of egg in water or toast water given instead. The 
infant should be kept quiet and have good air. In summer a change of air 
is often a necessity from seashore to mountains or from mountains to sea- 
shore. In and around New York City, use may advantageously be made 
of the Staten Island ferry and Coney Island and Long Branch boats for 
the sea air. Refreshing sponge baths should be given. Ten to twenty drops 
of whiskey may be given in water several times a day as a stimulant in 
selected cases. 

Drugs to check the diarrhoea are usually not necessary. Should the 
stools remain liquid in spite of the above outlined management, the follow- 
ing may be administered: 



M. Sig.: A teaspoonful every three hours. 

The medicine is to be stopped as soon as the diarrhoea is checked. 

In returning to milk feeding, we proceed cautiously. The breast is 
offered at longer intervals, and the bottle milk should be given in greater 
dilution and less frequently than before the attack. In warm weather the 
bottle food should be sterilized. 



Acute Gastroenteritis (Cholera Infantum). — In order to make it clear 
to all concerned that there is a vast prognostic difference between a dys- 
peptic and an inflammatory diarrhoea in infants, the term "summer diar- 
rhoea," which is used indiscriminately for diarrhoeas occurring in warm 
weather, should be dropped or used only in connection with simple diar- 
rhoea. The term " cholera infantum " is so universally employed in our 
country that it may be wise to retain it for all cases of acute gastroenteritis 
in infants, with the distinct understanding that we have to deal with two 
clinical varieties of this disease — the ordinary form and the choleraic form 
(grave form) , which differ only in severity, as do the ordinary and severe 
forms of scarlatina and other infections. Cholera infantum is an acute 
gastroenteric inflammation not due to exposure to cold or to teething, but 
due to bacterial infection of the gastroenteric tract and to the absorption of 
toxic products from fermentative and putrefactive changes in the stomach and 
intestines. It is in fact a case of milk poisoning from bacteria. In large 
cities cholera infantum becomes epidemic in June, July, and August, and, 



Bismuth, subcarb., 

Aq. cinnam., 

Tinct. opii, 




SEVERE ACUTE FORMS OF DIARRHCEA 



136 



PAEDIATRICS 



according to the investigation of A. Seibert, of New York, temperatures 
above 60° F. are provocative of epidemic diarrhoeas. This coincides with 
our knowledge of the turning point of milk, which is about 60° F. The 
summer heat, therefore, not alone 'produces a constitutional depression, but 
is at the same time a causative factor of the fermentative change in infant's 
food, milk. The bacteriology of the intestine in these cases has been care- 
fully investigated by William Booker, of Baltimore, and others in our 
country, and by Baginsky and Escherich in Germany, but they are unable 
as yet to formulate a bacterial nomenclature of inflammatory diarrhoea. 

Symptoms and Prognosis. — Cases may develop gradually and in the 
wake of dyspeptic diarrhcea (subacute form), or suddenly after symptoms 
of indigestion of short duration. Fever, thirst, retching, and vomiting 
are the initial symptoms. Diarrhcea soon sets in. The stools may be 
of any color, with flatus of foul odor and accompanied by pain. The 
diarrhcea may be very profuse, and after a day or two the stools show mucus. 
There is great prostration with restlessness, and the heart's action is rapid. 
If the conditions are unfavorable and no improvement sets in, death may 
ensue in stupor or convulsions with cerebral oedema (hydrencephaloid). 
A fall of temperature and of the pulse rate, a lessened frequency of stools, 
and cessation of vomiting are favorable symptoms. Children over two 
years old usually recover; infants are in great danger from this disease. 
Much depends upon early judicious management. In other cases the 
stomach irritation ceases, but the stools remain diarrhoeal with mucus 
and streaks of blood (ileocolitis). 

Prophylaxis. — Bottle fed infants should receive only sterilized food in 
hot weather. When a dyspeptic diarrhcea develops, the milk food should 
be stopped for a day or two and other food given. The child should be 
taken to the seashore or mountains or on day excursions. Children should 
receive sponge baths several times a day in the summer and cooled boiled 
water to drink. Overfeeding is bad. Weaning should not be attempted 
in hot weather. With such precautions cholera infantum is not apt to 
develop. 

Soxhlet's method of home sterilization of milk was introduced to the 
American profession in 1887, and its general adoption and the distribution 
of sterilized milk to the poor of New York City during the summer has 
resulted in a marked decrease of inflammatory diarrhoeas, which in ante- 
sterilizing days killed thousands of infants during the summer. It is now 
nothing unusual for colleagues practising among the middle and better 
classes to go through a summer without handling a single case of cholera 
infantum. 

Treatment of Cholera Infantum (ordinary type). At an early stage 
give no food for six to twelve hours. Give ice, peppermint tea, or black 
tea, to which may be added five drops of whiskey if a stimulant is needed. 
On the following day select as nourishment one, two, or three articles from 
the following list: Barley gruel, oatmeal gruel, white of egg in water, gum 
arable in water, cold tea, whiskey and water, lime water, bread water, 
mutton broth, cornstarch pap, burnt flour soup. 

If the vomiting persists, the stomach may be washed once or twice on 
that day. 



SEVERE ACUTE FORMS OF DIARRHCEA 



137 



The indications are: 1. To quench thirst; 2. To rest the gastrointes- 
tinal tract; 3. Antifermentative medication; 4. Stimulation and preven- 
tion of collapse. 

To meet indications 2 and 3 we employ the following drugs: 



B^ Bismuth, subcarb., 3j; 

Aqua? cinnam., gij; 

Tinct. opii, gtt. ij. 

M. Sig. : A teaspoonful every one to two hours. 

Or, 

B^ Acid, carbolic, pur., gtt. ij ad vj; 

Mucilaginis, §ij. 

M. Sig. : A teaspoonful every two hours. 

Or, 

R Argenti nitratis, gr. ij ; 

Aquae distil., 3ij- 

M. Sig. : A teaspoonful every two hours. 

Or, 

B, Resorcin, gr. ij; 

Aquae cinnamomi, 5 ij ; 

Tinct. opii, gtt. ij. 



M. Sig. : A teaspoonful every two hours. 

We avoid the addition of syrup to a mixture, if possible, and omit the 
opium if the patient apparently has little or no pain. When children are 
very restless, and show by their actions that they suffer pain, we do not 
hesitate to give small doses of opium, one, two, or three drops of the tincture 
in a two ounce mixture. In cases of circulatory failure with pulmonary 
oedema opium is contraindicated. A towel wrung out of cold water and 
secured over the abdomen appears to relieve pain, and a warm mustard 
bath stimulates in impending collapse. 

For obstinate vomiting we frequently give: 

R Tinct. iodin., gtt. xv; 

Aquae menthae, 3j; 

Syrupi simpl., 3ij- 

M. S. : Fifteen drops every hour. 

In obstinate vomiting stomach washing is indicated. A change of air 
is of the utmost importance. Children taken from a hot tenement to the 
seashore or any cool, shady place improve perceptibly in a short time, 
if not too far collapsed. Large enemata of tepid water, with or without 
the addition of some antiseptic drug (acid, salicyl.), should be tried in ob- 
stinate cases, but in dispensary practice this method cannot well be carried 
out. Stimulation must not be delayed until symptoms of collapse are 
marked. Young children with a high temperature, cold and clammy 
feet and hands, and a pulse too rapid to be counted, are frequently stimu- 
lated in vain. The best stimulations are: Camphor, strychnine, caffeine, 
enteroclysis, and hypodermoclysis. 



138 



PAEDIATRICS 



Their dosage and manner of employment are given in the chapter on 
General Therapeutics. Ice may be applied to the nape of the neck, and 
atropia sulphate may be given hypodermically in to -rh) grain doses. 

During the period of convalescence, the mucilaginous and farinaceous 
preparations already mentioned must be given until all danger of relapse 
is over, and eventually milk feeding (sterilized and modified cow's milk) 
is resumed. 

When there is a tendency to loose stools during the period of convales- 
cence the following astringent drugs may be ordered. 



fy Acid, tannic, gr. ij; 

Pulv. Doveri, gr. \; 

Chocolat., gr. v. 

Or, 

1$ Plumb, acet., gr. \\ 

Pulv. Doveri, gr. \; 

Sacchari, gr. v. 

M. S. : One powder four times a day. 

B. Bismuth, subnitrat., 3ij; 

Aquae, 5xiv; 

Ext. krameriae, 3j; 

Syrup., 5ij. 



M. S.: A teaspoonful four times a day. 

Tannigen and Tannalbin may prove valuable instead of plain tannin. 
Lozenges of tannate of quinine with chocolate are readily eaten by children 
on account of their pleasant taste. 

The severe form of acute gastroenteritis has a sudden onset with con- 
stant vomiting, high temperature, intense thirst, restlessness, cold surface, 
depressed fontanelles, glassy eyes, and early collapse. In consequence of 
the profuse drain from the stomach and bowels, the patient's body wastes 
rapidly, the eyes grow hollow, the nose becomes sharp, the cheeks fall in, 
and the features look pinched and drawn, while the flesh loses its elasticity, 
the abdomen is flaccid or shrunken, and the urine is scanty. 

Prognosis. — The prognosis in the severe form of cholera infantum is 
unfavorable. If infants survive the first two or three days, they may 
recover. 

Treatment of the Severe Form. — In the first stage food is a source 
of irritation and must be withheld for hours. It is well to wash the stomach 
and give cold water or cold peppermint tea to quench the thirst, also ice. 
The bowels should be irrigated with hot saline solutions to wash away 
putrid material and counteract collapse. The tincture of iodine prescrip- 
tion may be ordered. The surface circulation may be kept up by repeated 
hot packs or baths at 100° F. Black tea and whiskey may be given, and 
hypodermic stimulation employed. 

Py 01. amygdal., 5jv; 

Camphor., gr. xv. 

M. S. : Five to ten drops subcutaneously every three hours. 



MEMBRANOUS ENTERITIS, OR DYSENTERY 



139 



Or, 

1$ Sp. frumenti, 5ij; 

Fl. ext. digit., gtt. v. 

M. S.: Five to ten drops subcutaneously every four hours. 

When recovery takes place, farinaceous and mucilaginous drinks with 
yolk and white of egg in water may be fed for a week or until it is safe to 
return to diluted sterilized milk. 

ENTEROCOLITIS, OR FOLLICULAR ENTERITIS 

This is an infection of the bowel without marked gastric irritation. 

Symptoms and Prognosis. — Diarrhoea, blood streaked, mucous stools. 
Fever with constitutional depression, as in cholera infantum, and a less 
severe prognosis. 

The treatment is dietetic, medicinal, and local (irrigation of bowel). 
During the acute stage the dietetic management is the same as in acute 
cholera infantum. Bowel irrigation should be employed at once if for no 
other purpose than to bring away putrid material. Irrigation of the bowel 
is possible up to the caecum. Use a flexible tube. Elevate the hips. Irri- 
gate from one to three times a day with warm boiled water or starch water. 

Rectal suppositories to quiet pain: 
Ext. opii, 
Ext. belladonna?, 

Butyr. cacao, gr. v. 

M. S. : Use one to three a day. 

Reduce high temperature by baths and sponging. Medicinal antipyretics 
are not to be resorted to in diarrhoeal disorders. The graduated cool bath 
(reduced from 95° to 80°) , continued until the rectal temperature has mark- 
edly fallen, is the proper means in all cases in which the high tempera- 
ture calls for antiphlogistic measures. After the bath the warmth of the 
feet is maintained by hot water bags. 

MEMBRANOUS ENTERITIS, OR DYSENTERY 

A severe and often ulcerative inflammation of the lower bowel. 

Symptoms and Prognosis. — Bloody diarrhoea, with mucus, tenesmus, 
fever. Often fatal in infants. Older children frequently recover. 

Treatment is the same as for enterocolitis as regards diet and stimula- 
tion. In the way of medication, opium, bismuth, and astringent drugs 
are indicated when the dietetic management and bowel flushing alone 
are inadequate. In dysentery irrigation of the lower bowel with boiled 
medicated water is particularly useful. Use salicylic acid, 1 to 1,000, or 
argentic nitrate, 3j to 1 pint. 

The drugs to be given internally are the astringent drugs mentioned 
under cholera infantum. The antidysenteric serum treatment in cases 
of enterocolitis due to the Shiga bacillus has not been followed by note- 
worthy good results up to the present time. The dose of the serum is 
10 cc. injected once or twice a day. 




140 



PAEDIATRICS 



CHRONIC DIARRHCEA 

Chronic diarrhoea in children is usually dyspeptic or fermentative; 
sometimes neurotic; symptomatic, as in hepatic, cardiac, renal, and other 
disease, or due to a previous catarrhal and ulcerative colitis. 

The Management of the first two varieties has been sufficiently discussed 
under Acute and Chronic Indigestion. The symptomatic diarrheas will 
receive brief mention under the various diseases in which they occur. 
Generally speaking, their prognosis depends upon the underlying cause. 
If a child has a chronic diarrhoea associated with diabetes or some other 
fatal disease, the prognosis is bad; and if it is associated with conditions 
which can be bettered or removed, the prognosis is good. The Prognosis 
depends upon so many factors that it cannot be formulated en masse. 
Chronic diarrhoea is a grave disturbance in weaklings, but an absolutely 
hopeless attitude is not justified except in intestinal tuberculosis and 
other fatal diseases. 

The Management of a chronic symptomatic diarrhoea involves: Change 
of air, irrigation of the bowel, careful dieting, stimulation, and astringent 
medication. 

Specimen Diet. — Burnt flour gruel; slimy soup, with or without egg; 
cornstarch pap; scraped meat; mucilage of gum arabic; rice; farina; mashed 
potatoes; sterilized milk and lime water; buttermilk; albuminized food; 
tropon in mint tea; tropon with iron. 

In such cases the peptonized foods have rarely been satisfactory. Good 
buttermilk, recommended by the Dutch physicians, has given marked 
satisfaction in a number of cases. 

Medicinal Treatment. — Bismuth in large doses, 5 to 10 grains four 
times a day, with opium and with fluid extract of krameria. 

Tannic acid, 2 to 5 grains several times a day. 

Acetate of lead with Dover's -powder, gr. J of each three times a day. 
Tinct. Jerri, chlor., 5 drops three times a day. 
Lozenges of tannate of quinine and chocolate. 
As an aid to digestion the author employs: 

Acid, hydrochloric, dil., 
Tinct. quassiae, . 
M. S.: Five to ten drops in sugar water after eating. 

Stimulation is occasionally necessary with port wine, sherry wine, or 
blackberry brandy. 

Chronic Diarrhoea from Protracted Ileocolitis. — In protracted or chronic 
ileocolitis the catarrhal or rarely ulcerative changes in the intestine are 
frequently associated with bronchopneumonia or hypostatic congestion in 
the lungs, with large or fatty liver, and albuminuria (kidney congestion 
and nephritis). All this goes to show that a microbial diarrhoea was the 
starting point, and that the infection first located in the intestine has 
found its way into adjoining organs and tissues. 

Symptoms. — The symptoms are those of intestinal irritation and rest- 
lessness, flatulence, and occasionally colic with malnutrition and malas- 




CHRONIC DIARRHCEA 



141 



similation. The children waste to a skeleton, are anaemic, have fissured 
mucous membranes (with sordes) which bleed readily. The skin hangs 
loose and the mouth may be the seat of thrush or stomatitis. There may 
be half a dozen stools a day, and sometimes vomiting is observed. The 
stools are thin, often green, contain mucus, and are offensive. Under the 
microscope the stools are found to contain pus, some blood, food remnants, 
and epithelial debris. The lymph nodes (inguinal and abdominal) are 
generally enlarged, the skin of the abdomen has lost all its fat and is thin, 
and the dilated and atonic intestine (colon) bulges out under the flabby 
parietes. Skin excoriations and ulcerations are present over various parts 
of the body, due to poor surface circulation, the pulse is weak, the extremities 
are cold, respiration is shallow, and the temperature is often subnormal. 
Dropsy of the feet is occasionally seen. The nervous system is blunted 
and convulsions are rare. Toward the end an ordinary or tuberculous 
bronchopneumonia usually sets in. 

Chronic diarrhoea from intestinal ulcer may be due to simple ulceration 
in consequence of necrotic thrombosis of a small area of the intestinal mucosa 
or to syphilis or tuberculosis. Even malignant disease may be the under- 
lying cause. A careful local examination with the finger and speculum 
may reveal an ulcerated condition. Also there should be an examination 
of the stools. When the small bowel is the seat of a lesion, the pain is of 
a colicky character and the fasces give a bile reaction. When the lower 
bowel is affected there are tenesmus, mucus, and pain. 

Treatment. — Accessible ulceration will require local treatment in the 
way of rectal irrigation with nitrate of silver solution (5j to 1 pint). 
Ichthyol and tannin may be given internally, and suppositories per rectum 
to quiet pain (see Enterocolitis). The diet and medication are the same 
as for the other varieties. 

In chronic diarrhcea from mesenteric, intestinal, and peritoneal tuber- 
culosis or malignant disease of the bowel the treatment is symptomatic; 
medication will not cure. But almost every patient should have the benefit 
of the doubt and receive antisyphilitic treatment by inunctions of mer- 
curial ointment, with potassium iodide, internally. In chronic diarrhoea 
from peritoneal tuberculosis laparotomy should be clone, and it has saved 
lives. In older children suffering from ulcerative colitis a colonic fistula 
may be established and the bowel may be irrigated from above downward. 

Chronic mucous colitis in which mucous discharges are the prominent 
feature should be treated as a neurotic diarrhcea, and rectal irrigations 
should not be continued for any length of time in such cases. 

Amcebic Diarrhcea. — In this form living amcebse are found in the warm 
liquid stools (see Laboratory Diagnosis.) Their significance is not under- 
stood. The treatment is as for other forms of diarrhcea plus rectal douching 
with quinine bisulphate, gr. xx to 1 pint of water, or with ichthyol in 2 per 
cent watery solution, or irrigation through a colonic fistula in intractable 
cases (see also amcebic Diarrhcea in adults). 



142 



PEDIATRICS 



MALNUTRITION AND INTESTINAL TOXAEMIA (MARASMUS, 
RHACHITIS, SCURVY) 

Infantile atrophy (marasmus) is that form of malnutrition in infants 
and young children in which the child ceases to digest its food and gradually 
dwindles away and dies with all the symptoms of acute starvation. Starva- 
tion is a relative term in such cases, for it is not due to lack of food. The 
stomach may be regularly filled, but the power of extracting nourishment 
from the food is wanting. The infant grows thinner and more feeble daily, 




Fig. 52. — Rachitic Flat Foot in Child op Nine Months. 



and, worn out by purging, pain, and want of sleep, dies. This ailment 
occurs most frequently during the first half year of life. Atrophy of the 
thymus gland is usually found in cases of marasmus. 

The starting point may be an acute indigestion or inflammatory diarrhoea 
from spoilt food milk. If at the time a proper food is selected, the trouble 
is promptly overcome. If not, malnutrition becomes chronic and finally 
the period arrives when no amount of manipulation will save the child. 
Infants at the breast may show malnutrition to a certain degree, but seldom 
get into the atrophic, marantic condition. The symptoms are those of pro- 
gressive severe malnutrition (starvation), wasting, crying, little sleep, 
sunken fontanelles, stools scanty or diarrhceal, vomiting, ansemia, and 
flabbiness. 

Differential Diagnosis. — Marasmus must not be confounded with 
ordinary starvation, and we mi'st remember that mesenteric or intes- 



MARASMUS AND RICKETS 



143 



final tuberculosis or syphilis may be the underlying cause of a wasting 
process. 

Prognosis in a case of advanced atrophy in a young infant is bad, but 
no case should be given up as hopeless when the heart is sound and the 
lungs and kidneys are free. 

Treatment. — Change of air from sea to mountain, or from mountain 
to sea, cleanliness of the mouth, and warm sponge baths. For young infants 
a wet nurse should be obtained. Top milk diluted, 1 to 3, sterilized or 
Pasteurized in summer, raw in cold weather, should be fed, the strength of 
the milk to be increased gradually. The stomach should be washed once 
a day if vomiting is a prominent symptom, particularly in older children. 
Whey and cream may be given, or asses' milk if it can be obtained. If a 
milk idiosyncrasy appears to be established, select from the list of sub- 
stitute foods recommended for such conditions (see Difficult Feeding 
Cases). Subcutaneous injections of blood serum have been tried in 
infantile atrophy with negative reszdts 
thyreoid extract has also been tried and 
found useless. Hypodermic injections 
of salt water (one ounce a day) have 
apparently benefited some patients. 

RICKETS, RHACHITIS 

A peculiar manifestation of malnu- 
trition or impaired nutrition. Rickets, 
like gout, has local and general mani- 
festations most marked in the first two 
years of life. The bones and cartilages 
show characteristic changes. The epiph- 
yses persist, and the medullary canal 
shows an excess of unfinished bone pro- 
duction (osteoid tissue). The stability 
of the skeleton is subnormal. These 
changes take place at the time of the 
best growth of bone (one to two years) . 
Fcetal rhachitis is described. In rha- 
chitis the general nutrition is below 
par, and changes occur in various organs. Marked fatty tissue may be 
observed. Some children become emaciated, particularly if suffering from 
severe diarrhoea. The muscles are flabby and soft (pseudo-paralysis). 
Bronchitis, pneumonia, enteritis, enlargement of the liver and spleen, 
spasmus glottidis, eclampsia, and tetany are noticed. The children have 
capricious appetites and walk late or lose the power of walking; the teeth 
come late; the cranial bones are soft (craniotabes) . The fontanelles remain 
open. It has been shown that there is no lack of assimilation of lime salt 
in rhachitic children, and it is more likely that in rhachitis we have to deal 
with a diseased condition of the bone-forming cells. 

Rhachitis is associated with a faulty diet and hygiene. It is a common 
disorder in bottle fed children and particularly such as fail to get meat 




144 



PEDIATRICS 



broth and farinaceous gruels with their milk after the seventh or eighth month. 
Whereas chronic intestinal indigestion will often end in scurvy, rhachitis 
may develop in children who have shown little or no intestinal catarrh and 
intestinal toxaemia. 

Clinical Forms of Rickets. — Bone Rickets. — Craniotabes (soft cra- 
nium); rosary at the ribs; chicken breast; rhachitic spine; curvatures of 
the spine; bow legs; knock knees; square cranium (caput quadratum, 
with hydrocephalus combined); deformed clavicles; flat foot; pelvic de- 
formity, etc. ; enlargement of the epiphyses, etc. 

Muscle Rickets. — In rickets the muscles become flabby and powerless 
{'pseudoparalysis) . Children who have walked, fail to walk. 

Fat Rickets. — This term is used when children show only slight changes 
in the bone and are excessively fat. Pot belly is the term in vogue to desig- 
nate the large abdomen of 
rhachitic children. Of ner- 
vous symptoms, we have 
laryngismus, tetany, convul- 
sions, nystagmus, head nod- 
ding, tics, hydrocephalus, 
sweating of the head. 

Generally speaking, rha- 
chitis is accompanied by a 
tendency to catarrh of all 
mucous membranes and a 
feeble resistance to other in- 
tercurrent disease. 

Rheumatic and scorbu- 
tic changes in and near the 
joints or epiphyses may be 
distinguished from rhachitic 
swellings by means of x rays. 
Rhachitic bone gives only a 
faint shadow in the x ray 
print. To discriminate be- 
tween rickets and joint 
manifestations of congenital 
syphilis is difficult, in the 
absence of a syphilitic his- 
torjr. Infants are frequently 
rhachitic and syphilitic at 
one and the same time. 

Prophylaxis and Treat- 
ment. — To prevent a child 
from becoming rickety, we 
must carefully attend to its diet, its digestion, and its hygiene. This in- 
volves all that has been said under Infant Feeding, breast, mixed, or 
bottle feeding. At the end of the seventh month meat broth and gruel 
with yolk of egg should be fed twice a day in addition to the five bottles 
of milk food. Children must live outdoors in good weather and sleep in 




Fig. 54.- 



-Carrying-Frame for Feeble Rhachitic 
Children. 



SCURVY IN CHILDREN 



145 



cool rooms, and they must have a daily movement of the bowels:" A similar 
management must be enforced to prevent children who are rickety from 
becoming more so. Children a year old and over may have rice, sago, 
farina, hominy with egg, beef broth, and toast crumbs, and may nibble 
a chop bone. The milk should be 
rich in fat. 

Of drugs, iron, arsenic, phos- 
phorus are lauded and appear in- 
dicated. 

Syr. ferri iodid., 10 drops three 
times a day. 

Fowler's solution, 1 drop three 
times a day. 

Elix. phosph. (U. S. Ph.), 5 to 
15 drops three times a day. 

Thompson's solution of phos- 
phorus, 10 drops three times a day. 

Such drugs are to be admin- 
istered for two to four weeks 
and then discontinued for a week 
or two. 

The thyreoid therapy, recom- 
mended for rhachitis, has been 
tried by the author in the Babies' 
Ward of the New York Post Grad- 
uate Hospital without showing 
noteworthy results. Malt prepa- 
rations and fruit juice are ser- 
viceable for children one year old 
and over. 

Bow legs and knock knees are 
rectified surgically by osteotomy. 

The results are good. A rhachitic Fig. 55. — Rhachitic Deformity. 

thorax and spine may need gym- 
nastics and orthopaedic management (see Orthopaedics) . Fractures of long! 
bones (green stick fractures) and epiphyseal detachments require splinting'! 
Laryngismus stridulus is managed by means of cold sponge baths and; 
bromide of sodium internally. In a few instances, and in urgent cases, 5 
the writer has tubed the larynx for hours and once for a week with very- 
satisfactory results in cases of laryngismus. 

SCURVY IN CHILDREN 1 

Scurvy is an acquired " hsemorrhagic diathesis " from intestinal putre- 
faction and toxaemia. This view is the more plausible if we remember that 
in hepatic," renal, and other disease we frequently notice in the later stages; 
" hsemorrhagic " phenomena which we may attribute to the same- causes, 

1 See collective investigation on Scurvy in America, by the American Psediatric 
Society. 

11 





Fig. 56. — Rhachitis. Fig. 57. — Rhachitis. 

Genu Varum before operation. Genu Varum after operation. 




Fig. 58. — Rhachitis. Fig. 59. — Rhachitis. 

Genu Valgum before operation. Genu Valgum after operation. 



SCURVY IN CHILDREN 



147 



viz., intestinal putrefaction and toxaemia. In adults the lack of fresh 
vegetables in the diet was formerly looked upon as the causative factor in 
scurvy. This view is erroneous. The Arctic explorer, Mr. Nansen, person- 
ally told the writer that during his three years' trip in the Fram not one case 
of scurvy developed among his party, and he attributes this remarkable 
immunity to the careful sterilization of all the perishable food taken along. 

Pellagra, Maidismus, the so called Alpine scurvy, is due to the use of 
diseased maize as food. Scurvy in children 
follows the prolonged use of improper food. 

Sterilizing, Pasteurizing, or cooking of 
milk is not per se responsible for the scurvy 
condition. Scurvy may develop in infants 
and children fed on breast milk, cow's milk 
(raw, sterilized, or Pasteurized), condensed 
milk, proprietary foods, etc. Out of 379 
cases reported, only 12 had scurvy at the 
breast; all the others were bottle fed. 
Scurvy may be prevented, therefore, by 
selecting for each individual bottle fed child 
the food which it will digest and upon which 
it will thrive and gain. 

Characteristic Symptoms in Scurvy are: 
Anaemia, pain on motion or handling, dis- 
coloration of the gums, subcutaneous and 
free hemorrhages, swellings about the joints, 
spontaneous detachment of the epiphyses 
from the shafts of the bones, etc. Pain is 
clearly a very prominent symptom of the 
disease. Generally it is evident only when 
the child is moved or tries to move itself. 
Sometimes it is so intense that the approach 
of any one to the bedside is sufficient to 
cause the child to scream out through fear of 

being touched. The legs are Usually flexed. Fig. 60.— Infantile Scurvy and 

Local swelling (haemorrhages) may in- Marasmus (F. Huber). 

volve the soft tissues or may be subperios- 
teal. Protrusion of one or both eyes is probably due to orbital haemorrhage. 
The gums are slightly swollen or discolored, spongy and ulcerated, and 
frequently bleed on being touched. A purpuric eruption and petechiae 
are sometimes seen, and occasionally spontaneous haemorrhages from the 
gums, nose, bowels, stomach, and genitourinary tract. 

Fractures in infantile scurvy are usually separations of the epiphyses 
merely and are rare. Fever'is often present but is not a prominent symptom. 
Ancemia and malnutrition are usually present and the percentage of haemo- 
globin is much reduced. 

Prognosis is favorable if the disease is recognized in good time. 

Treatment. — Change of food, preferably to raw milk in cold weather; 
fruit juice or hydrochloric acid; cleanliness of the mouth; fresh air; treat- 
ment of any underlying cause ; bowel washing. 




148 



PAEDIATRICS 



Differential Diagnosis. — It is necessary to make a differential diagnosis 
between scurvy and the following diseases: 

Rheumatic or Gonorrheal Arthritis. — The joints, not the bone shafts, are 
involved; fever is high; characteristic scurvy symptoms are absent. 

Rhachitis. — Rhachitic rosary; no 
marked pain; no ecchymosis or pe- 
techial or spongy gums; rhachitis and 
scurvy may coexist. 

Purpura. — No history of improper 
feeding; rapid improvement of scurvy 
under treatment. 

Infantile Paralysis. — Sudden onset 
with fever; difference of electrical re- 
action in the two diseases. 

Syphilis may coexist with scurvy. 
The difference in the history must be 
taken into consideration. 

Stomatitis. — This has none of the 
associated symptoms of scorbutic sore 
mouth. 

WORMS IN CHILDREN 

The alimentary tract in children is 
apt to harbor three kinds of worms : 

Fig. 61.— Tuberculous Peritonitis ROUND WORM (ASCARIS LuMBRI- 
with Ascites. COIDES) ; PlN OR SEAT WORMS (OXYURIS 

Vermicularis) ; Tapeworm (Taenia). 

The round worm is brown in color and is from four to eight inches long. 
It usually inhabits the small intestine. 

Symptoms and Diagnosis. — Colicky pain with occasionally a blood 
streaked stool may lead one to suspect worms. A positive diagnosis is based 
upon the passage of the parasite or the recognition of its ova in the stools. 

Treatment. — A dose of maltine with cascara at night and one grain of 
santonin with sugar the following morning, to be repeated five or six times 
for five or six consecutive days. 

The pin worm inhabits the large intestine and rectum, and has been 
found in the appendix (case of Dr. Inslee H. Berry, of New York city). 

Symptoms and Diagnosis. — Pin worms produce intense itching at the 
anus, and may be picked out of the anus in children. 

Treatment. — A strong decoction of garlic in milk is injected with a 
piston syringe or fountain syringe once or twice a day after a cleansing 
enema of soap suds. Camphor ice or cold cream may be applied to the anus 
to overcome the itching and pruritus. 

The Tapeworm. — A tapeworm gives symptoms, but the only certain 
indication of the existence of the worm is the passage of the links or a section 
of the worm. 

Treatment. — One week before administering the tapeworm remedy, 
five drops of oil of turpentine and five drops of compound spirits of ether 
should be given on sugar three times a day. One day before administering 




TUBERCULOUS PERITONITIS IN CHILDREN 



149 



the remedy, a saline aperient should be given. The following is then given 
in the morning at 8, 8.30, and 9 a.m.: 

1$ Ext. filicis maris seth., fl., oij; 

Emuls. ol. ricini, oij; 

Ext. rhei fluid., ) __ 

Ext. aloes fluid., ] aa ' gtt,V; 

Syrup., ovj. 

M. Sig. : Give in three doses. 

After the worm is out it should be examined in order to determine 
whether the slender portion with the small head has passed. A second 
dose of the tapeworm remedy may be given in a day or two if the worm has 
not passed and the patient is not weak from the effects of the first dose. If 
children vomit the medicine, it may be given by stomach tube. Salicylic 
acid is also used as a tapeworm remedy. 
It is given in divided doses, forty grains 
in one day, followed by a dose of castor 
oil. 

TUBERCULOUS PERITONITIS IN 
CHILDREN 

The infection of the peritonaeum may 
come about by way of the circulation or I f*i 

from the gastroenteric or genitourinary 
tract. It may readily take place in chil- 
dren without an antecedent history of 
tuberculosis. 

The diagnosis of tuberculous peri- 
tonitis is based upon the abdominal 
symptoms, such as distention, pain, and 
disturbed bowel action, and the presence 
of fluid and loss of weight, and is made n 
by exclusion, except in those cases in 
which the tubercle bacilli are found, and 
then the diagnosis is positive. A febrile 
rise of temperature of an irregular type 
has been found in all cases under careful 
observation. There is nothing charac- 
teristic about the temperature curve. Fig. 62.— Tuberculous Peritonitis 
The fluid is an inflammatory exudate. OF Two Years Standing. 

Cases of chronic non-tuberculous ser- 
ous peritonitis present usually the features of an ordinary ascites, the abdom- 
inal fluid being free, whereas it is usually not free in the tuberculous variety. 
It is rare to find the tubercle bacilli by microscopical examination of puncture 
fluid. In doubtful cases the opening of the abdomen is indicated and will do 
no harm. Paroxysmal pain in the abdomen of children, in the absence of 
chronic appendicitis or abdominal fluid, is not indicative of tuberculous dis- 
ease and is frequently overcome by dieting and attention to and irrigation of 
the bowels. (See Worms, Intestinal Indigestion, Membranous Enteritis, etc.) 




150 



PEDIATRICS 



A routine test with tuberculin in human beings in the present unsatis- 
factory state of our knowledge of its action is hardly justified. 

Clinical Varieties of Tuberculous Peritonitis. — 1. Chronic tuberculous 
ascites (miliary form); 2. Fibrocaseous tuberculous peritonitis; 3. Fibroadhe- 
sive tuberculous peritonitis; 4. Tuberculous peritoneal tumors; 5. Tubercu- 
lous ulcer of the intestine and appendix 
with adjacent miliary tuberculosis of 
the peritonaeum; occasionally purulent 
peritonitis from perforation of a tuber- 
culous ulcer. 

Treatment. — In the present state 
of our knowledge, simple laparotomy is 
the best treatment for tuberculous 
peritonitis. The opening of the ab- 
domen is, as a rule, followed by an ar- 
rest of local disease symptoms, and it 
may be followed by a disappearance 
of the tuberculous deposits on the per- 
itonaeum, as shown by certain cases in 
which the abdomen has been opened 
for some reason or other for the second 
time. The futility of medicinal treat- 
ment was experienced by the writer in 
a series of forty-one cases which were 
subsequently treated by operation. 
Where some form of medication is fol- 

Fig. 63.— Tuberculous Peritonitis lowed by improvement or cure, one 
and Hernia. must not forget that spontaneous cures 

Apparent Cure after Herniotomy. have also been reported and observed 

in cases presenting all the clinical evi- 
dences of the disease. After opening the abdomen direct medication by 
iodoform emulsion or flushing with normal salt solution may be employed. 
Finally, the indication is an early operation, which is no doubt of very 
great benefit to the patient when the tuberculous process is limited to 
the peritonaeum. As regards the establishment of a complete cure, one 
may be somewhat sceptical, because of the persistence of mild abdomi- 
nal symptoms, of irritative catarrh or inflammation in the bronchi, lungs, 
pleurae, and intestines, in cases which remain under observation after 
operation. If at the time of operation we have coexisting tuberculosis of 
the lung or pleura, the ultimate results are unsatisfactory, although some 
improvement usually takes place for the time being. 

DISEASES OF THE RESPIRATORY TRACT IN CHILDREN 

INTRODUCTORY REMARKS 

This group of ailments centres around the symptom cough. Cough 
is a reflex phenomenon usually due to irritation in the respiratory tract. 
The tendency to " colds " and cough is most marked in anaemic, rhachitic, 




CATCHING COLD 



151 



syphilitic children and in children who are housed and who sleep in over- 
heated rooms, in children of tuberculous antecedents, and in children who 
have chronic malarial disease, or who are suffering from other chronic ail- 
ments. In addition to such general underlying conditions we have local 
irritation to take into consideration, such as is furnished by the presence 
of swollen follicles (follicular pharyngitis) or of adenoid vegetations or of 
enlarged tonsils and peribronchial tuberculous glands. 

These statements apply to the entire group of respiratory ailments, and 
in the management of children subject to " colds " and cough all these points 
must be taken into consideration. It will not suffice simply to order an 
expectorant or cough mixture. Children should sleep in cool rooms and 
not be burdened by heavy woolen underwear, in which they are apt to per- 
spire on the least exertion. It is 
important to keep the feet warm 
by wearing good stockings, but 
it is bad policy to keep the neck 
protected by furs and wraps, 
except in extreme weather. In 
neurotic children and adults we 
frequently observe a "nervous 
cough " which we are unable to 
locate. In the absence of local 
and constitutional causes, fresh 
air and a cool sponge bath daily 
are to be recommended for such 
conditions. Hot drinks are good 
expectorant mixtures, and a 
water trip, or absence from the 
dust laden city air is the best 
cough mixture, even in mild 
febrile cases of long standing. 
For harassing cough at night a 
few drops of paregoric with wine 
of ipecac may be appropriate. 

Adenoids and large tonsils Fj(J 64.— Tuberculous Peritonitis with Cys- 
must be removed, and swollen T i C Accumulation of Fluid. (Operation.) 

follicles should be cauterized. No relapse or symptoms after four years. 

In protracted cases one or two 

doses of quinine may be given as a therapeutic "feeler " for malaria, even 
in cases in which the blood is free of Plasmodium malaria, and occasionally 
potassium iodide will promptly check a harassing or long standing cough. 

CATCHING COLD 

The rationale of the causation of the ordinary "cold" by reason of 
localized or general chilling of the body is made plausibly clear by recent 
studies on the bactericidal power of the blood of animals exposed to cold. 
It has been found that by chilling the surface it is possible to reduce the 
number of antibodies in the blood to a very marked degree. This means 




152 



PAEDIATRICS 



that the body is deprived of a goodly proportion of its defensive weapons, 
and therefore under such conditions it easily falls a prey to infections of 
all sorts. On the other hand, repeated exposure to slight degrees of cold 
brought about an increase of antibodies, and this observation therefore 
affords a theoretical justification of the practically approved methods of 
"hardening " the body by hydrotherapeutic and other methods of training. 

Simple Acute Rhinitis, Pharyngitis, Laryngitis, Tracheitis, and Bron- 
chitis are names given to the mild infectious catarrhs of the upper and 
lower respiratory tract, according to localization. 

The Symptoms are sneezing, lacrymation, coughing, moderate fever, 
loss of appetite, and a sensation of chilliness with mucopurulent secretion 
in the terminal stage. The mild forms last two to three days; the severe 
forms one to two weeks. 

A persistent nasal catarrh with excoriation at the nostril is strongly 
.suggestive of diphtheria, and a culture should be made and antitoxine 
, administered if the Klebs-Loefner bacillus is found. 

Mild overlooked nasal diphtheria with a free pharynx and subsequent 
measles and laryngitis and ultimate diphtheritic croup form a clinical sequence 
which has surprised many a colleague. The possibility of syphilis should 
also be borne in mind. 

In coryza there is a nasal discharge. In pharyngitis the pharynx is 
red and dry and there is hoarseness. In rhinitis, pharyngitis, and laryngitis 
,we should examine carefully for diphtheritic patches in the nose and throat. 
Bronchitis and the measles eruption go hand and hand, as do pharyngitis 
and scarlet fever. 

Treatment of a "Cold." — In uncomplicated mild cases of catarrh 
in the upper respiratory tract the children are put to bed and a laxative is 
administered. Hot and cold drinks are given and a fluid diet or fever diet 
is appropriate. To wash away secretions and disinfect the nasopharynx, 
.a few drops of salt water are poured into the nostrils by means of a spoon, 
^every three to four hours, or an albolene spray may be used for the nose and 
throat. Older children may take three to five grains of saccharinate of 
quinine or euquinin. The management of laryngitis with a croupy cough 
and stridulous breathing is discussed. under Croup. 

The general hygienic management has been outlined in the introductory 
remarks. If children do not promptly recover, the urine should be examined 
and. a general careful examination should be made, to detect if possible any 
further complications. It will not suffice to order cod liver oil and trust 
to luck, as in the good old days. Incipient tuberculosis can often be recog- 
nized by a careful examination, and frequently can be arrested and cured 
by energetic hygienic and dietetic management. 

The Clinical Features of Acute Bronchitis in Children 

Bronchitis is an inflammation of the mucous membrane of the bronchi. 
It may be unilateral, but is usually bilateral. It may be primary and 
represent an extension of a "cold " beginning in the upper air tract, and 
it may be secondary to or accompany many other forms of disease and 
is a common ailment in ill nourished and rhachitic children. 



BRONCHITIS AND BRONCHOPNEUMONIA IN CHILDREN 153 



Symptoms. — In the mild form of bronchitis we observe cough, acceler- 
ated breathing, a moderate rise of temperature, loss of appetite, vomiting, 
restlessness, and often a wheezing respiration. In the severe forms, which 
cannot be distinguished clinically from bronchopneumonia, the dyspnoea 
is more marked. The respiration may be 60 to 80, with slight cyanosis. 
The chest is filled with coarse moist rales. Attacks of respiratory failure 
are observed and occasionally we have the clinical evidence of acute 
emphysema. 

The prognosis is favorable except in the severe form, which is often 
fatal to young infants, whereas older children usually get well. 

Differential Points. — Bronchitis may be the first symptom of measles 
and whooping cough and may indicate an irritation from inflamed and 
enlarged ■peribronchial glands. 

Treatment. — A mild bronchitis is managed like any other form of 
" cold." In the winter the child is put to bed in a room heated to 70° F. and 
a change from one room to another is advisable. The patient should 
receive an enema and a warm bath and should have cool water to drink. 

Diet. — Soft diet for older children. Infants take their usual liquid 
nourishment. As soon as the febrile stage is over children should be taken 
out of doors in fine weather. The nasopharynx should be kept moist by 
instilling ten drops of salt water into each nostril several times a day. In 
tardy convalescence, two or three grains of quinine in a teaspoonful of 
compound elixir of taraxacum may be given once or twice for the purpose 
of counteracting any underlying malarial factor. To check a harassing 
cough, five to ten drops of paregoric may be given once or twice, particu- 
larly at night. In the severe form of bronchitis the treatment is identical 
with that of bronchopneumonia. 

Poultices, jackets, and inhalations are probably useless and are not 
employed by the writer. The protracted cough during the convalescence 
stage is favorably influenced by a change of air and mild cauterization of the 
nasopharynx with a five per cent solution of argentic nitrate. An albolene 
spray applied through the nostrils often relieves local irritation and cough. 

Throat Coughs of Children. — Hypertrophied tonsils cause a constant 
cough, which becomes severely spasmodic at times. 

Adenoids cause a frequent hacking sort of cough, as in beginning tuber- 
culosis, due to the postnasal catarrh present in such cases. 

Cough due to Granular Pharyngitis and its accompanying catarrh is 
characterized by its onset with emotional disturbance, as at the beginning 
of laughing or crying. Frequently the cough is of a dry and rasping char- 
acter and the little patient is compelled to clear his throat frequently, with 
the expectoration of small pellets of gray sputum. 

The treatment is directed to the cause. 

BRONCHOPNEUMONIA IN CHILDREN (Catarrhal Pneumonia, 

Capillary Bronchitis) 

Definition. — An infectious, diffuse pulmonary catarrh or inflammation 
without the typical " hepatization " which is characteristic of lobar pneu- 
monia. The portal of entrance for the various microbes responsible for 
this condition is the respiratory tract. 



154 



PEDIATRICS 



The predisposing factors are, in the first place, the general ones appli- 
cable to all microbial infection or disease, viz.: lowered vitality from any 
and all causes (malnutrition, rhachitis, exhausting diarrhoeas, malarial, and 
any, cachexia, and the breathing of impure dust and germ laden air). The 
breathing of pure cold air is not in itself a source of danger. Children who 
live and sleep in overheated and ill ventilated rooms are apt to suffer from 
all forms of infectious respiratory troubles. House infections in schools, 
school dormitories, and overheated and carpeted living apartments are 
daily occurrences among the rich and the poor alike. It is at all times diffi- 
cult and frequently impossible to escape infection of some kind or other; 
but the time is ripe for abandoning the superstition and ignorance which 
invite infection by fostering and perpetuating the fear of breathing cold 
air. Rational precautions against catching cold need not be neglected. 

Our knowledge of the bacteriology of bronchopneumonia is only frag- 
mentary. The pneumococcus, staphylococcus, and streptococcus are 




Fig. 65. — Temperature Curve in a Case of Septic Bronchopneumonia in a Child, 

Ending in Recovery. 



principally in evidence, and the streptococcus infection appears to be the 
most septic and fatal. The secondary forms of bronchopneumonia com- 
plicating measles, whooping cough, scarlet fever, diphtheria, ileocolitis, 
influenza, and other diseases are all mixed infections. 

Symptoms. — When the onset is sudden, or as a sudden exacerbation in 
bronchitis, we observe high fever, cough, rapid and embarrassed respiration, 
and sometimes cyanosis. The temperature curve is not characteristic 
as in the lobar variety of pneumonia. In some instances there is a low 
febrile temperature and the pulse is generally rapid and becomes weak with 
increased prostration. Convulsions are not frequent; late convulsions 
are ominous. Delirium and restlessness are observed. The digestion is 
poor, and tympanites with dyspeptic diarrhoea and vomiting complicates 
the situation. The urine is scanty and high colored and may show albumin, 
as in any other acute infectious disease. 

Physical Signs. — Fine subcrepitant rales and sibilant, rough, coarse, 
and musical rales may be heard over one or both sides. Small scattered 
areas of dulness or atelectasis come and go, with bronchial breathing over 
the dull areas. To bring out the auscultatory signs the children must be 



BRONCHOPNEUMONIA IN CHILDREN 



155 



made to cry. In some of the protracted and severe forms of broncho- 
pneumonia the physical signs are almost nil, and in others the physical signs 
approach very nearly to those of the lobar type of pneumonia. 

Clinical Varieties. — 1, Mild or moderately severe primary broncho- 
pneumonia, often beginning as a mild bronchitis, with convalescence in 
eight to ten days; 2, Septic form, lasting from three to eight weeks; 3, 
Rapidly fatal form of from one to three days' duration; 4, Bronchopneu- 
monia secondary to other infections and of a varying degree of severity. 

Termination and Sequelae. — 1, Complete recovery; 2, Death; 3, Chronic 
bronchopneumonia with and without emphysema; 4, Empyema; 5, Tuber- 
culosis of the lungs; 6, Complications affecting the pleura, the meninges, 
the pericardium, the gastroenteric tract, the ear, and the kidneys. 

Prognosis. — Bronchopneumonia is a serious disease in children, and 
particularly in acute septic cases and in exhaustion from previous illness. 
In bottle fed young infants in baby hospitals the mortality is above 50 per 
cent; in private practice, even among the poor, the mortality is far less. 

Prophylaxis. — All cases of pneumonia should be isolated, and where a 
house infection is suspected it is best to remove the well children to another 
house for the time being. A child with bronchitis should have a few drops 
of salt water poured into the nostrils from a spoon three times a day and 
should live in good air. A trip on the water is a better tonic and expectorant 
than any form of medication. Difficult feeding cases in young infants 
should not be kept in children's hospitals for any length of time, on account 
of the patients' proneness to contract bronchopneumonia. 

Treatment. — A child suffering from bronchopneumonia should receive 
a warm mustard bath of 100° F. and an enema or laxative and be put to 
bed in a well ventilated and sunny room. 

Diet. — Infants should receive the breast or bottle and plenty of boiled 
water between times. Older children may take food as here outlined: 

Beef broth and egg, eggnog, soup, cereal decoctions, toast in milk, lady 
fingers, custard, milk, ice cream, apple sauce, beef jelly, boiled water 
(cooled), ginger ale, cocoa, pineapple juice, orange juice, mint tea, green or 
black tea. Tropon, which is about 90 per cent protein, may be given in 
water, tea, or milk. 

In acute febrile conditions, the food must be fluid or semifluid and in 
a form which will not overtax the feeble digestive apparatus or leave a 
large residue for decomposition and local irritation in the bowel. 

Hydrotherapy. — Fever with great cerebral restlessness is best man- 
aged by some form of hydrotherapy. A temperature of 104° or even 105° 
is in itself no catise for anxiety, but, if coupled with restlessness and fleet- 
ing delirium, should receive special attention. An ice cap or cold coil to 
the head and flushing the bowels with cool water will reduce the tempera- 
ture. A warm mustard bath at 100° F., reduced to 90° or 80° while the 
patient is in the bath, is a safe measure. A child may remain ten minutes 
in the water, and should be rubbed during the time, then wrapped in 
blankets, and put to bed and warm water bags applied to the stockinged 
feet. A cool sponge bath (water and alcohol) applied under a blanket 
is a safe procedure. Very restless children become more quiet if a cold 
compress is placed around the chest and renewed every two hours. Such 



156 



PEDIATRICS 



a compress appears to act as a mild counterirritant, and when applied 
elicits a few deep inspirations, which are desirable. The writer has not 
observed any special benefit from the wearing of an oil silk jacket or a 
poultice. Such a contrivance is more soothing to an anxious mother than 
to a feverish child. 

As the nasopharynx is apt to become dry in feverish children with 
rapid breathing, it should be moistened three or four times a day by pouring 
into each nostril ten to twenty drops of a one per cent salt solution by 
means of a spoon. An albolene spray is also useful for this purpose. 

When the tongue is heavily coated, it is wise to aid digestion by ad- 
ministering hydrochloric acid. The following prescription is well suited 



for this purpose: 

R^ Acid hydrochloric, dilut., 5j; 

Ess. pepsin., . §ij. 

M. S. : A teaspoonful four times a day. 

For frequent vomiting the following prescription may be administered: 

1$, Tinct. iodini, gtt. x; 

Aq. menthse, 3vj; 

Syrup, sacch., 3 i j - 



M. S. : A teaspoonful every two hours until vomiting is checked. 

It is a good rule to give only one medicine at a time and if possible to 
get along without drugs. 

Rectal Alimentation. — In all septic fevers in which digestion is 
below par we notice a loss of strength with emaciation, in which event rectal 
alimentation may be useful. From two to four ounces of an oil emulsion 
should be injected into the rectum three times a day. 

Before giving a nutritive enema, the bowels should be flushed and 
cleansed. Rectal alimentation will probably not have much influence in 
counteracting the pernicious action of bacterial toxines on the nerve 
centres. 

General Treatment. — Stimulants and expectorants are indicated when 
the pulse shows weakness, and when a loose rattling cough is accompanied 
by prostration or the "typhoid " state. Camphor, ammonia, ether, strych- 
nine, and nitroglycerine may be given. In bronchopneumonia secondary 
to some other disease stimulation may be necessary from the beginning. 
(For stimulation, see chapter on General Therapeutics in Disease.) 

Urgent dyspnoea is best combated by means of heart stimulants and 
expectorants and mild general massage. Artificial respiration is not to be 
overlooked in the management of such a condition. When the patient is 
cyanotic and the surface veins are filled, venesection may be helpful in older 
children. (See Venesection.) 

Oxygen inhalations are much in vogue. Their precise value in our 
remedial paraphernalia is unknown, but they appear to do no harm. 

When the acute stage of bronchopneumonia is passed and the disease 
continues in a mild way, it is well to remember that syphilis and chronic 
malarial disease are frequent substrata of acute infectious disorders. 



ACUTE LOBAR PNEUMONIA IN CHILDREN 



157 



Therefore it is rational even in the absence of the Plasmodium in the blood, 
to give a few doses of quinine or iodide of potassium as a " feeler." 



1$ Quinin. sulph., gr. x; 

Elix. tarax. comp., 5j- 

M. Sig. : A teaspoonful twice a day. 

1$ Potass, iodid., 5ss.; 

Spt. ammon. anisat., 3ss. ; 

Syrup, simplicis, 3ij; 

Aquae, ad, gij. 



M. Sig.: A teaspoonful four times a day. 

Potassium iodide is, moreover, an expectorant, and may be given per 
rectum, and quinine carbamide may be given in solution subcutaneously 
if necessary. When convalescence is tardy, the patient should be drugged 
as little as possible and should receive the stimulating and invigorating 
effects of fresh air. One should not hesitate to send feeble children 
with a slight rise of temperature to the seashore and have them take short 
trips on the water, stopping all medication. In tuberculous bronchopneu- 
monia intermittent high fever continues and the children waste away. 
In the absence of a sputum examination this condition must be inferred 
from its clinical manifestations. 

Chronic bronchopneumonia with and without acute attacks of " asthma " 
and progressive emphysema is frequently met with in children's practice. 

In such cases much can be accomplished by careful management of the 
nasopharyngeal and digestive tracts. Such cases require pure air and 
cool sponging. The patients must have regular bowel action and must 
not be tortured by being compelled to wear thick flannels; protection from 
cold temperatures is best gained by means of heavy outer garments. Medi- 
cation is useless, but the potassium iodide expectorant mixture is indicated 
in intercurrent attacks of mucopurulent bronchitis. 

ACUTE LOBAR PNEUMONIA IN CHILDREN (FIBRINOUS, OR 
CROUPOUS, PNEUMONIA) 

This is an acute infection of the lung by the pneumococcus. The portal 
of entrance is naturally the respiratory tract. There are three stages in 
the course of this form of pneumonia: 1. Congestion; 2. Hepatization; and 
3, Resolution. Recovery from the disease is usually ushered in by a 
critical sudden defervescence. 

The mortality from lobar pneumonia in children is greatest in the first 
year of life, and it is not high in children above two years of age, a vast 
number of cases terminating in complete recovery. Mortality statistics in 
lobar pneumonia are not trustworthy, on account of the difficulty of dis- 
tinguishing between lobar pneumonia and bronchopneumonia. 

Symptoms. — The onset is sudden or occurs during a mild attack of 
bronchitis with vomiting and chill. 

Pain, which is not always present, is often referred to the abdomen. 
Pain in the right side of the abdomen, with tympanites, simulates appen- 



158 



PEDIATRICS 



dicitis. The temperature is from 103° to 105° in the general run of cases. 
The pulse is full, strong, and from 120 to 130. The respiration is from 
30 to 50. The cough is short and occasionally painful ; there is no expectora- 
tion. The face is flushed and there is restlessness, with a coated tongue, 
loss of appetite, and thirst, also mild or active delirium, and convulsions 
(occasionally). Leucocytosis is generally to be observed. About the 
seventh day the temperature drops to normal or subnormal and marked 
improvement is manifest. Convulsions indicate a violent onset, but not 
necessarily a grave prognosis. Convulsions at the time of resolution are 
ominous and indicate meningeal complications or circulatory failure with 
inanition of the brain. 

Clinical Varieties in Children. — The usual localization is in the inferior or 
middle lobe, to which the inflammation is limited or from where it may spread. 

Apex -pneumonia is also common and may be accompanied by severe 
delirium, sometimes convulsions. The cough is short and gagging. 

Central Pneumonia. — The localization is deep seated, and it may take 
from four to five days before the localization is clearly demonstrable. 

Double Pneumonia. — This is a grave condition with urgent dyspnoea, 
but not so fatal as in adults, particularly if one side clears up before the 
other. In one-sided pneumonia the unaffected lung of the other side 
may be congested, which condition gives the mistaken idea of a true double 
pneumonia. 

Abortive pneumonia differs in the ordinary form only in duration and 
rapidity of defervescence, which may take place at the end of two or three 
days. This form gives rise to the mistaken idea that pneumonia can be 
aborted by drugs now in use. 

Wandering pneumonia is characterized by steady advance of consolida- 
tion from lobe to lobe. 

Massive Pneumonia. — The physical signs simulate effusion because the 
air cells and bronchi are filled with exudate. 

Physical signs, in acute lobar pneumonia in children. — 

1st Stage : Congestion. — Weak respiration sounds, crepitant rales on 
deep inspiration or expiration. 

2d Stage : Consolidation. — Dulness on percussion, increased vocal 
fremitus, bronchial breathing. The latter may be temporarily absent when 
a large bronchus is filled. In children dulness, fremitus, and bronchial 
breathing may be observed in pleuropneumonia with effusion. 

3d Stage : Resolution. — The physical signs are practically the same as 
in the first stage. The rales are moist. 

Disease Conditions Simulating Lobar Pneumonia. — Hypostatic conges- 
tion and pulmonary oedema give dulness at the base, weak breathing 
sounds, rales, and dyspnoea. The history of the case and the absence of 
bronchial respiration and of the typical high temperature will usually clear 
up a doubtful case. 

In bronchopneumonia the physical signs are those of a diffuse bronchitis 
with scattered small areas of dulness. It is sometimes impossible to dis- 
tinguish one form from the other. 

Acute tuberculous pneumonia is not an unusual manifestation in young 
children of tuberculous parentage. The history, the high temperature 



ACUTE LOBAR PNEUMONIA IN CHILDREN 



159 



curve, often remittent, the dyspnoea with cyanosis, and the loss of flesh 
will lead to the recognition of this ailment. Its occasional massive lung 
dullness will give the impression of fluid in the chest, but it is found to be 
absent on puncture. In infants a diagnosis between lobar pneumonia and 
bronchopneumonia is often impossible. The post mortem room shows 
frequent errors in this respect. 

Pleurisy with effusion in young children should not be mistaken for 
pneumonia, on account of the marked difference in the physical signs. In 
obscure cases a puncture will determine the presence or absence of fluid. 

Treatment. — We have at the present time no specific drug which will 
abort or cure lobar pneumonia. The disease is self-limited, usually ending 
in recovery, and medication plays a minor role in its management. A 
child taken ill with pneumonic inflammation should receive a warm bath, 
at 100° F., an enema, or two to five grains of calomel, and should be put to 
bed in a well ventilated room, at about 68° F. A young child should receive 
the breast or bottle and plenty of cool boiled water to quench thirst. Older 
children are put on liquid diet: Beef broth and egg, soup, gruel, toast in 
milk, lady fingers, custard, stewed apples, milk, water, ice cream, ginger 
ale, pineapple or orange juice, tea or mint tea, tropon, cocoa, junket, calves' 
foot jelly. 

The appetite in acute febrile disease is always below par, and a change 
to peptonized food is in the vast majority of cases not called for. A few 
drops of dilute hydrochloric acid in sugar water three times a day will aid 
digestion, and this is a rational routine prescription in febrile and other 
disease for patients above one year of age. 

When the time for a critical drop of temperature has arrived and the 
fever continues, we must look for complications or we may recognize an 
extension of the pneumonic inflammation to adjacent territory or we con- 
clude that we have been mistaken as to the kind of pneumonia present. 
When dulness persists for several days, after the critical drop of temperature, 
it means delayed resolution or a pleuritic exudate. In delayed resolution 
the child should be carried into the open air daily or taken to the seashore 
or country ; iodide of potassium may be given per rectum (five grains twice 
daily) in an ounce of warm water or by mouth. 

Potassii iodid., 5ss. ; 

Spt. ammon. aromat., 5ss.; 

Syrup, simplicis, 3ij; 

Aquae, ad, S i j . 

M. Sig. : A teaspoonful every three hours in water. 

Children with tuberculous antecedents may take maltine and creosote. 

High temperature with cerebral restlessness is managed by hydrotherapy 
and the ice cap, not as a rule by drugs. While the patient is in the bath 
the temperature of the water may be reduced from 100° to 80° F. Sponge 
baths are serviceable in mild cases of pneumonia. 



160 



PEDIATRICS 



Circulatory Failure and Stimulation 

In lobar pneumonia circulatory failure is due to sepsis and pulmonary 
obstruction combined. In general practice a moderate rise of pulse and 
temperature appears to be the indication for the administration of the 
various heart drugs in use at the present time. It is questionable whether 
early and promiscuous stimulation is in the interest of the patient. Un- 
fortunately, the indications for stimulation are by no means clearly under- 
stood, and no doubt in many instances we credit happy results to some 
particular drug or method, when the inherent reserve power of the heart 
alone is responsible for the recovery of the patient. Taking this view, it 
would appear a more rational plan to adopt enteroclysis for early stimula- 
tion, instead of drugs. 

Enteroclysis stimulates through the abdominal sympathetic and pro- 
motes kidney secretion and thereby elimination of septic products. More- 
over, it promotes intestinal absorption of water whenever the body craves it. 
Intestinal irrigation is performed with the aid of Kemp's double current 
flexible tube or a plain soft rubber catheter. The fluid used is a solution 
of salt ( 3j to 1 pint) at 110° F., and the flow is kept for ten minutes. Me- 
dicinal stimulation with alcohol, camphor, caffeine, strychnine, digitalis, or 
nitroglycerine may be employed in urgent cases in connection with entero- 
clysis, but in the majority of instances children get well without drugging 

PLEUROPNEUMONIA-PLEURISY WITH SEROUS EFFUSION 
AND PYOTHORAX IN CHILDREN 

GENERAL REMARKS 

Physical diagnosis as applied to the thorax gives such positive evidence 
of abnormal conditions that it would seem impossible to overlook a general 
or localized pleuritic exudate or be in doubt as to its presence or absence in 
a given case. It is, however, a daily occurrence for mistakes to be made 
in this direction, for faulty conclusions to be arrived at from a faulty in- 
terpretation of symptoms and physical signs, and for the presence of pus 
within the thorax not to be recognized. 

The infection of the pleura is occasionally primary, but takes place 
principally through direct extension from the bronchi or lungs and from 
purulent affections of other organs, and through a metastatic process. 
External injury followed by infection also takes place; exposure to cold 
should be looked upon merely as a predisposing agent. 

Pleuropneumonia with effusion is found in children of all ages. The 
diagnosis is made by the physical signs to be discussed under Empyema 
and by exploratory puncture. The symptoms are those of severe pneumo- 
nia, the dyspnoea being particularly distressing. The prognosis is grave. 
Very young children rarely recover. In older children the outlook is not 
so unfavorable. 

Pleurisy with Serous Effusion. — Primary pleurisy is infrequent in chil- 
dren. Its onset is insidious, with fever of an irregular type and with pain. 
Shortness of breath is observed as soon as the effusion sets in. The 



PLEUROPNEUMONIA AND PYOTHORAX 



161 



signs of fluid in the chest are discussed under Empyema. Friction sounds 
may be heard above the level of the fluid. The character of the fluid is 
elicited by puncture. 

Prognosis. — Most cases end in recovery. 

Pyothorax. — The vast majority of empyemata are secondary to pneu- 
monia, pulmonary gangrene, pulmonary tuberculosis, pertussis and erup- 
tive fevers with catarrhal or fibrinous pneumonia, pericarditis or peri- 
tonitis, or are sequelae of rheumatic infection, infectious nephritis and 
perinephritis abscess, osteomyelitis, diphtheria and " croup," typhoid fever, 
gout, pyaemia, ulceration of the trachea, oesophagus, and stomach, appen- 
dicitis, or abscess of the liver or spleen. 

Pyothorax developing during typhoid fever is not at all rare; pyothorax 
developing after pneumonia following intubation for diphtheritic stenosis 
is exceedingly rare. As to the time of year that most cases of empyema 
in children are observed, it is evident that cold and damp weather, which 
is the predisposing factor in bronchial and pulmonary catarrh and inflamma- 
tion, is also the predisposing factor in empyema. Thus, we see more cases 
in February, March, and April than in the nine other months of the year. 
The pulmonary type of influenza is responsible for quite a number of cases 
of empyema. Emp)rema is a common disease in children under five years, 
and it may be stated in a general way that one third of all pleuritic effusions 
in children are of the nature of pus or seropus. 

. In gangrene of the lung and in pyopneumothorax due to traumatism 
a stinking, septic pus is found. Pus is frequently found streaked with 
blood. A sanguineous pleuritic exudate, such as is found in tuberculosis 
and occasionally observed as a complication in articular rheumatism, is 
very apt to become pus. Occasionally inspissated pus is found. A colloid 
substance representing inspissated serous exudate is very rare. Chylous 
effusion has been observed and mistaken for pus. The upper layers may 
consist of seropus, the lower layers of thick creamy pus ; loose and adherent 
pseudomembrane is often found. Occasionally the quantity of pus ob- 
served does not exceed an ounce, and frequently it reaches one, two, or three 
pints. 

We have unilateral, bilateral, free, and multilocular encapsulated pyo- 
thorax, in which latter case one pus sac may be drained without emptying 
the other. The bilateral form may be primary or follow pulmonary gangrene, 
typhoid fever, tuberculosis, etc. The thoracic abscess may be interlobar, 
anterior, posterior, lateral, or located on the diaphragm. 

After these general preliminary remarks on the subject of pyothorax 
we will confine our attention to the diagnostic points, our consideration 
of which will embrace the physical diagnosis of fluid in the chest. A purulent 
fluid is distinguished from a serous fluid by the aspirating needle alone 
and not by any set of signs or symptoms. The presence of peptone in the 
urine in cases of pyothorax is by no means a distinguishing feature. Von 
Jaksch has found peptonuria in scurvy, in intestinal ulceration, in the third 
stage of pneumonia, and in syphilis. Furthermore, in making our diagnostic 
enquiries, we must always bear in mind the occurrence of hydrothorax, 
free or localized and sacculated, in consequence of disease of the heart, 
lungs, or kidneys. 
12 



162 



PEDIATRICS 



Subacute cases of pleurisy with irregular temperature curve, pain, 
cough, and dyspnoea due to effusion will be readily recognized by a careful 
observer. The change of a simple pneumonia into a pleuropneumonia is 
also not very difficult to recognize. Children with simple pneumonia 
cry readily and apparently without much effort or pain. A child with 
pleuropneumonia will give evidence of pain when it is handled and in crying. 
In pleuropneumonia the respiration is rapid and superficial and occasionally 
intercepted. Diaphragmatic respiration stops and the entire thorax is 
lifted in the efforts of respiration. 

The puzzling cases are the very acute ones in which, in the absence of 
expectoration, the initial symptoms of pneumonia and pleurisy in children 
are about the same, i. e., fever, pain, cough, rapid breathing, and dyspnoea, 
and where (1) critical defervescence takes place with dulness on percussion 
continuing, or (2) a continued irregular temperature curve extends over 
the second and third weeks of illness with marked dulness persisting. (See 
Unresolved Pneumonia or Effusion.) In such cases the question arises: 
Have we a pulmonary dulness to deal with or an effusion or both? And 
what is the nature of the effusion? Our decision is based on inspection, 
palpation, auscultation, percussion, and puncture. 

Examination. — Inspection. — Rational signs of fluid: 1, Lateral curvature 
of the spine; 2, Lack of movement of the affected side; 3, Bulging of the 
affected side; 4, Bulging or retraction of the intercostal spaces on inspira- 
tion; 5, Displaced heart; 6, Dyspnoea; 7, Cutaneous oedema; 8, Enlarge- 
ment of the subcutaneous veins; 9, Pallor of the skin. 

All these signs may be present or most of them absent in empyema; 
moderate dyspnoea on exertion is usually noticeable in pleuritic effusion, 
also bulging of the affected side when massive effusion is present. On deep 
inspiration the intercostal spaces become convex, but occasionally we notice 
a retraction or concavity of the intercostal spaces on inspiration in the 
presence of fluid. Pallor and loss of appetite are generally noticeable in 
cases of pyothorax. A displaced heart is not commonly seen, but must 
necessarily be noticed in massive effusion on the left side. Cutaneous 
oedema and enlarged veins are occasionally present. Lateral curvature 
of the spine is seen in cases of long standing, and where a chronic sinus 
has existed we find marked curvature, a deformed chest, a shrunken side, 
and a depressed shoulder. 

Fever. — Fever in pyothorax is irregular and sometimes absent, as in 
cold abscesses in other parts of the body. 

Palpation. — Rational signs of fluid: 1, Bulging of the lower inter- 
costal spaces on inspiration; 2, Absence of vocal fremitus. 

If the finger tips are pressed upon an intercostal space, an outward 
bulging will be felt on inspiration in the presence of fluid. This sign, how- 
ever, is not always present in hydrothorax or pyothorax, and is generally 
absent in the presence of small exudates or in cases of rhachitic thorax 
with a very narrow intercostal space. 

Vocal fremitus is usually absent over a fluid, and educated finger tips 
will map out a small localized sacculated exudate with nicety. Bacelli's 
sign, a diminished fremitus in the presence of thick exudates, cannot be 
relied upon to distinguish serum from pus. In some instances fremitus over 



PHYSICAL DIAGNOSIS OF FLUID IN THE CHEST 



163 



a fluid is present, but diminished as compared with the sound side or as 
compared with the fremitus over the region of the compressed apex of the 
lung of the affected side. This is readily understood if we remember that 
vibrations may be communicated to the chest wall by means of localized 
pleural adhesions. In order to enable the examiner to note the pres- 
ence or absence of fremitus, the children must be made to cry. The cry is 
usually weak. 

Auscultation. — Rational signs: 1, Absence of respiratory murmur; 2, 
Weak voice, cry, or cough; 3, Noisy respiration. 

The absence of the respiratory murmur is a classical sign of the presence 
of fluid in the thorax, but there are exceptions to this rule, as in the case of 
a consolidated lung with compression or occlusion of the bronchus. 

A thin layer of fluid surrounding the lower part of a lung will not obscure 
the breathing sounds. When a thoracic abscess has been partly expecto- 
rated through a perforation into a bronchus, moist rales may be heard over 
the affected side, which is still dull on percussion. Tubular breathing 
may be heard over fluid, transmitted from a pulmonary dulness on the 
affected or the opposite side and due to compression or inflammation of 
the adjacent or underlying lung. Catarrhal pneumonia with pyothorax 
will give all the usual varieties of rales, and the same is true of hypostatic 
pneumonia or pulmonary oedema and pyothorax. 

Friction sounds are heard before and after exudation, but not over 
fluid. Diminished vesicular breathing, perceptible fremitus, and dulness 
speak for thickened pleura or membrane or new growth. In empyema 
the trachea may be so obstructed that inspiration and expiration are 
impeded and a noisy and croupy respiration is present. iEgophony is 
occasionally heard in the axillary line in the presence of large exudates. 
Pseudocavernous signs in the shape of amphoric tubular breathing are 
sometimes met with in children, suggesting the presence of tuberculous or 
non-tuberculous cavities in the lung. This phenomenon is particularly 
misleading when associated with the noise of the cracked pot on percussion. 
Bronchophony is heard over consolidated lung tissue, not over fluid. The 
voice and cry in empyema are weak; the cough is weak, short, and gen- 
erally moist. 

Percussion elicits flatness and marked resistance to the finger in con- 
ditions of fluid in the thorax. On the right side this merges into the area 
of liver dulness. A rhachitic flat chest or deformed thorax gives apparent 
dulness on percussion and occasionally misleads the examiner. Dulness 
of the posterior right thorax in infants is not always pathological, and is 
frequently due to compression by a large liver during forced crying. This 
dulness disappears during inspiration. A pathological dulness remains 
during inspiration and expiration. A consolidated lung, thickened pleura, 
thoracic new growth, hypostatic pneumonia, or pulmonary oedema shows 
dulness on percussion. A massive pneumonia with the bronchi plugged 
with fibrin may present an almost flat percussion sound and undue re- 
sistance to the finger; in such cases the increased fremitus will establish 
with great probability, but not with certainty, the absence of fluid. 

In the presence of a thin layer of fluid forced percussion brings out the 
percussion sound of the underlying lung. In copious exudates the flatness 



164 



PEDIATRICS 



may reach the clavicle and extend beyond the sternal margin of the affected 
side. When the lung is pressed into the apex by a fluid, the lower area is 
flat on percussion with absence of breathing sounds and absence of fremitus, 
and in the apex over the compressed lung we find high pitch dulness, tubular 
breathing, and increased fremitus, also, occasionally, in a pliable thorax, 
we obtain the sound of the cracked pot on percussion just below the 
clavicle (pseudocavernous sign). In apex dulness, with absence of breath- 
ing sounds and absence of fremitus, a localized anterior abscess may be 
suspected. 

A marked resistance to the finger on percussion is of very great value as a 
diagnostic sign, and will often establish the presence of fluid. The degree 
of dulness and resistance on percussion depends principally upon the thick- 
ness of the layer of fluid. 

A marked displacement of neighboring organs is rarely found on per- 
cussion in children. In one case of pyothorax on the right side I found the 
heart beat in the left axillary line. The alteration in the height of fluid on 
change of position and the curved line of Ellis and Garland are indistinct 
manifestations in children. To appreciate the finer phenomena as elicited 
by percussion, it should be practised with the fingers only. 

Now, bearing in mind the variability of the physical signs and rational 
symptoms of fluid within the thorax, it is evident that occasionally in a 
given case the aetiology is important in order to appreciate the physical 
conditions present. When an unresolved pneumonia is suspected and an 
empyema overlooked, we generally have a history of pneumonia with 
critical defervescence and a subsequent rise of temperature, with continued 
dulness on percussion. 

When we suspect fluid, we can prove its presence or absence best by means 
of the aspirating needle, and as regards the character of the fluid, this is es- 
tablished by the aspirating needle and in no other way. 

To make a probatory puncture the following should be observed: The 
patient is made bare to the waist and the site for puncture is cleansed with 
ether and 1-1,000 bichloride solution. The child is held firmly in the lap 
of its nurse and the arm of that side which is to be attacked is raised high 
and kept in this position, thereby securing a larger intercostal space. The 
physician firmly presses the tips of his left index and middle fingers into 
the selected space as a guide (not lower than the eighth interspace) and with 
the right hand, armed with a clean syringe and a rather large needle, punc- 
tures the interspace midway between the finger tips. The needle should 
be introduced from one to two inches, as the case may be, and the piston 
drawn out. The needle may now be pushed slowly forward or it may be 
slowly withdrawn. Lateral movements are not permissible unless the 
needle is in a pus cavity, for fear of tearing the lung tissue and producing 
pneumothorax or subcutaneous emphysema, several instances of which 
have come to my notice. 

If all signs point to fluid and none is found, a second and third puncture 
may be made. If the needle enters a pus sac, pus will show, if it is only 
a drop. Should the needle be arrested before entering a pus cavity or be 
pushed beyond a pus sac or enter dense adhesions or a new growth or a 
thick pseudomembrane (pus membrane), pus will not show. A gelatinous 



EXPLORATORY PUNCTURE IN PLEUROPNEUMONIA 



165 



exudate or thick inspissated pus will not pass through a very fine needle. 
A serous exudate mixing with a few drops of a disinfecting solution within 
the syringe may cause the aspirated fluid to look turbid and be mistaken 
for seropus, therefore the exudate removed should be examined under the 
microscope. 

When the needle is withdrawn the puncture wound is at once secured 
with sticking plaster or thin rubber tissue made sticky by means of a drop 
of chloroform or ether. Puncture on the right side should be made so as 
not to injure the diaphragm or liver. If the puncture is made not lower 
than in the eighth interspace, such injury is improbable, as the liver and 
diaphragm are pressed downward by the weight of the exudate. If punc- 
tures are made in the manner described, there is not the slightest danger 
of infecting the thoracic cavity thereby. When a serous exudate becomes 
pus it is through infection from within. 

When the presence of pus is shown by the needle, the treatment indicated 
is that of any abscess, whether it be unilateral, bilateral, free, or localized. 
A deep lung abscess with adhesions of both pleura? is treated like a localized 
empyema. In abscess of the mediastinum we find a fluctuating tumor at 
the border of the sternum. In purulent pericarditis we should strike pus 
over a pyriform precordial dull area with no evidence of cardiac shock. 
Occasionally the symptoms of purulent pericarditis are very obscure and 
misleading. A peripleuritic abscess of metastatic origin may be mistaken 
for empyema. 

Lung abscess, lung hernia, thoracic new growths, and echinococcus of 
the thorax have been observed in children and mistaken for empyema. 

Very interesting from a diagnostic and practical point of view are cases 
of multilocular pyothorax. In these cases the pyothorax is readily ascer- 
tained with the needle, but the multilocular and encapsulated pus sacs 
are first recognized during or after the operation, and make incision in 
various places necessary. The following case has come under the writer's 
notice: 

A young lad had contracted amoebic diarrhoea in Central America and 
come North for treatment. There was flatness over the posterior aspect 
of the thorax on both sides, and the liver dulness was enlarged. A puncture 
through the eighth interspace on the right side gave pus of a chocolate 
brown color. A puncture at the seventh interspace of the same side gave 
a clear watery liquid, and the same watery effusion was found on the left 
side. The condition was clearly one of hepatic abscess which had perforated 
through the diaphragm into the thoracic cavity and was encapsulated. In 
addition there was hydrothorax of both sides. 

The pulsating character occasionally observed in empyema is due to 
forcible heart action. 

Termination. — Empyema in children usually ends in complete recovery 
if operated upon in time. When the lung expands and the pus cavity heals 
by granulation, a thickening of the pleura with adhesions results, as shown 
by slight dulness and diminished breathing over the affected side. In 
some cases a fistula will remain for a considerable length of time after 
operation, with ultimate recovery, or death ensues from tuberculosis, 
amyloid degeneration, or exhaustion. 



166 



PAEDIATRICS 



Treatment of Pleuropneumonia. — The management of pleuropneumo- 
nia is the same as in pneumonia. When fluid is suspected and found by 
puncture, its removal (if pus or seropus) is immediately indicated. (See 
Treatment of Empyema.) If only clear serum is found, its removal by 
aspiration or incision through the intercostal space is indicated only in 
urgent dyspnoea. When puncture reveals a turbid fluid containing pus 
elements, a single incision in the intercostal space will let out the fluid, 
and a shred of iodoform gauze may be introduced into the pleural cavity 
to act as a drain. This procedure gives immediate relief, and the infant 
will be in a better condition to stand other operative interference (resection 
of a rib) should such become necessary. 

In pleurisy the patient receives a warm mustard bath and a stiff dose 
of calomel and is put to bed. A cold compress is placed around the chest 
and renewed every hour or two. The diet is the same as in pneumonia. 
Although medication plays no role in the management of pleurisy with 
serous effusion, it is an undoubted fact that some cases do remarkably well 
under the administration of sodium salicylate (three to five grains four 
times a day) . If malaria or syphilis is suspected as an underlying condition, 
iodide of potassium may be given per rectum, or the syrup of iodide of iron 
by the mouth, or quinine by the mouth. 

The removal of fluid by aspiration or incision and drainage is indicated 
only when its massive accumulation endangers life from pressure upon the 
heart and lungs. If no absorption of fluid takes place after four weeks, 
the removal of a few ounces by aspiration appears to start spontaneous 
absorption. 

When tuberculosis is suspected as an underlying cause, the young 
patient should lead an outdoor country life with the hope of throwing off 
the disease. 

Treatment of Pyothorax. — Resection of a portion of a rib under anaes- 
thesia and drainage of the abscess cavity is the treatment for empy- 
ema. Irrigation of the abscess cavity is not usually practised unless the 
pus is foul and stinking. If the patient is in collapse, anaesthesia is dan- 
gerous. In such cases it is better to cut rapidly through the intercostal 
space and relieve pressure by allowing some of the fluid to flow out. Hy- 
podermic stimulation and enteroclysis may tide the patient over the critical 
period and subsequently resection of a rib may be done under ether in 
the usual way. 

Chronic empyema necessitates further surgical treatment, after which 
the patient should be sent to the mountains, to the seashore, or to a con- 
valescent home for fresh air treatment until the discharge ceases and the 
wound is closed. Patients should not be detained in city hospitals for 
any length of time after operations for pyothorax, as recovery is more rapid 
in the country or at the seashore. 

Where operative interference is not resorted to, recovery may take place: 

1. By perforation into a bronchus with expectoration of pus. 

2. By perforation between two ribs, usually in the fifth interspace, or 
both these conditions may be present. 

3. Recovery by gradual absorption of a small exudate of pus. Such 
recovery is rare, 



FEVER FOLLOWING OPERATIONS FOR PYOTHORAX 



167 



A perforation into a bronchus may exist without allowing the exit of 
pus until intrathoracic pressure has been diminished by aspiration or 
incision. An external perforation may be cribriform, and a sound introduced 
may strike a rough rib (denuded of its periosteum by pus erosion) , suggest- 
ing caries of the spine or rib. The pointing external pus sac. may be pulsat- 
ing in character. Perforation into the oesophagus has been reported, also 
cases of perforation through the diaphragm, the pus passing down behind 
the peritonaeum as in cases of psoas abscess. 

Secondary abscesses following pyothorax are a constant occurrence, 
such as otitis media, purulent pericarditis, phlegmon of cervical region, 
periostitis, purulent meningitis and peritonitis, abscesses of the scalp, 



M ) I I I | I I I I I I 




Fig. 66. — Fever Curve in Tuberculosis of Lung and Unresolved Pneumonia Com- 
pared in Cases of Empyema. 



gluteal region, eyelids, etc. Such secondary pus deposits are found in cases 
that have been operated upon as well as in neglected cases. 

As a rule the pleuritic exudate is in contact with the general circulation, 
as shown by the presence of drugs (chemicals) in the exudate. 

The reinflation of a collapsed lung exposed to the pressure of the atmos- 
phere through an opening in the pleural cavity is a paradox. 

The Significance of Fever following Operations for Pyothorax 

It may be stated that a completely apyretic course after empyema 
operations is exceptional. Assuming that in a given case of pyothorax 
the proper surgical procedure has been accomplished, we might expect, where 
the temperature has been high before operation, a fall of temperature 
and a normal or nearly normal temperature curve during convalescence. 
It is well known, however, that in a large number of cases a rise from the 
normal takes place at once or at various times during the further course 
of the disease, and as this fever temperature almost invariably indicates 
an extension of the disease or a complication of some kind, grave or trivial, 
it becomes a matter of great importance to correctly interpret such fever 
and remove any source of irritation if present, and, if possible, to remedy it 



168 



PEDIATRICS 



before the patient is exhausted. The correct interpretation of fever after 
an empyema operation is in some instances extremely simple and in others 
extremely difficult, and it will not suffice to inquire simply into the matter 
of drainage and, if such appears satisfactory, to overlook other factors 
equally important. 

The following are some of the causes for fever temperatures after opera- 
tion for pyothorax: 

Faulty drainage, slipping of a drainage tube into the thoracic cavity, 
intoxication with iodoform or carbolic acid, retention of urine, constipa- 
tion, secondary extrathoracic abscess, eruptive fevers, wound infection, 
malarial fever, extension of the original inflammation to the other side 
or to other parts, unresolved pneumonia, coexisting tuberculous broncho- 
pneumonia, nephritis as a complication, deep seated multilocular abscess, 
mild or severe general sepsis, and irritation from a drainage tube too long 
in place. 

Thus a rise of temperature may mean very little, but it always indicates 
something which we should endeavor to locate and correct. The successful 
management of pyothorax is not alone a matter of incision and drainage, 
but calls for accurate clinical investigation and observation. A carefully 
kept record of temperature furnishes valuable evidence as to the underlying 
cause of fever. 

WHOOPING COUGH; PERTUSSIS 

This is a contagious disease due to a microorganism of unknown nature 
which probably finds foothold in and about the larynx and by its presence 
provokes a spasmodic reflex cough. It attacks children of all ages, and 
young children are particularly susceptible. If, after an exposure, two 
weeks pass without the development of a cough, the probabilities are that 
the disease has not been contracted. The average duration of the spas- 
modic stage is one month. It is not definitely known whether or not per- 
sonal contact is necessary for infection. It starts as a catarrhal bronchitis, 
then turns into whooping cough with vomiting spells, and gradually dimin- 
ishes in severity. After subsiding, it may start up again after a so-called 
fresh " cold," and last for from three to four months, particularly in winter. 

There are no characteristic physical signs by which we can diagnosticate 
pertussis, except the "whoop." In infants whooping cough is often fatal; 
in children over four years it is seldom fatal. During the paroxysm there 
is severe heart strain, and a small number of the patients have chronic 
emphysema of the lung after recovery. In others the vesicular emphysema 
is not permanent. 

The complicating phenomena and clinical varieties are: Mechanical 
visible haemorrhages ; bronchopneumonia and emphysema with and without 
fever; convulsions (asphyxia or intracranial haemorrhage); indigestion, 
diarrhoea, vomiting; heart strain with albuminuria; paralysis in whooping 
cough of cerebral or peripheral origin (infrequent) ; stomatitis and sub- 
lingual ulcer. Sublingual ulcer may be due to the friction of the tongue 
against the teeth or it may be of contagious or parasitic origin. 

Management. — The best treatment for whooping cough is the fresh air 
treatment. 



WHOOPING COUGH; PERTUSSIS 



169 



Children with pertussis must be quarantined, but not confined to the 
house. The patient must live out of doors. A warm place at the seashore 
is the best location. The writer has known violent whooping cough to 
cease in three days on board an ocean steamer. If possible, the children 
should be changed from one cool sleeping room to another. The rooms 
in which they are confined should be well ventilated at all times day and 
night, and the air should not be vitiated by burning a "cresolene " lamp. The 
nasopharynx should be lubricated and kept clean by instilling mild salt 
water solution into each nostril four times a day, or by spraying albolene 
into the nose and throat. 

The only drug which has given the author any satisfaction in treating 
whooping cough is antipyrine, of which one, two, or three doses (gr. i, ii, 
or iii) are given at night. Opium or belladonna may be given at the same 
time in exceptionally violent cases. In complicating bronchopneumonia 
with much secretion, camphor and hyoscyamus as a stimulant and expecto- 
rant may be given, also warm baths. Systematic compression of the thorax 
(artificial respiration) aids in expelling the secretions and is indicated in 
cyanosed children. For the management of convulsions in whooping cough, 
see Convulsions. 

A paroxysm of whooping cough can be cut short by pressing the lower 
jaw forward and downward, as in asphyxia. Mother, nurses, and other 
attendants should be instructed in its use in order that the oncoming 
attacks, especially at night, may be arrested. Ozone inhalations in whoop- 
ing cough have been employed. Such inhalations undoubtedly have a 
distinct curative effect as regards the duration and severity of the disease. 

The following quotation is from a communication on the subject (Trans- 
actions of the American Pediatric Society, 1892) : Seven cases of pertussis 
were treated with ozone inhalations. The ages of the children ranged from 
eighteen months to seven years. Each case was well marked and of average 
severity. The cases were first treated in the second and third week of 
illness, at which time the paroxysmal cough is well developed. Two to 
three inhalations of fifteen minutes each were given daily, and all the cases 
were discharged after two weeks' treatment, except one case which was 
treated four weeks. No drugs were given, but salt water was dropped 
into the nose three times a day. The improvement became manifest 
after the first three to four inhalations. The children slept better during 
the night after inhaling ozone, and the youngest child under observation 
usually went to sleep after each inhalation. Unfortunately an efficient 
ozone generator is too expensive for general use in the homes of patients." 

In very severe cases of whooping cough with frequent spells, much 
vomiting, and rapid loss of flesh and strength, intubation may be tried 
after all other rational treatment has been unavailing. 

Pseudo, or False, Whooping Cough. — A throat cough with a whoop is 
a frequent sequela of influenza and yields promptly to local treatment. 
Cauterization with 2 per cent nitrate of silver solution and albolene or salt 
water spray through the nostrils into the pharynx are to be employed. 



170 



PAEDIATRICS 



THYMUS GLAND; ENLARGEMENT AND ABSCESS 

The thymus gland is situated in the anterior mediastinum; its function 
is unknown. It is small in the new-born, increases in size up to the end 
of the second year, remains unchanged until about the end of the tenth 
year, and diminishes in size until puberty, when it entirely or nearly disap- 
pears. When the thymus gland is enlarged it gives a substernal dulness 
on percussion, which is more readily elicited when the child is held hori- 
zontally, face downward, and percussion is practised from underneath. This 
dulness may also be due to enlarged peribronchial glands, in which case 
the predominance of percussion dulness is usually on one side, and other 
swollen lymph nodes are present in the lower region of the neck. The 
thymus gland may be present as an arched elastic swelling in the median 
line above the sternal notch. It may become hypersemic or hsemorrhagic 
from the various causes which induce congestion, and it may suppurate 
or participate in a tuberculous process. 

Enlargement of the thymus interferes with respiration and circulation. 
It may give rise to an inspiratory stridor often mistaken for laryngospasm. 
Sudden death from an enlarged thymus may have for its cause compression 
of the air passages or compression of the large vessels leading from the heart. 
These deaths are a mystery without a post mortem examination. The 
following case will give a fair idea of " sudden death in a case of enlarge- 
ment of the thymus." Intra vitam the infant was occasionally slightly 
cyanotic and had spells of rapid and laborious breathing. On two occasions 
it had convulsive seizures. Auscultation revealed a loud systolic murmur 
at the base of the heart with the valve sounds clear and distinct. The 
murmur was not transmitted in any direction. The infant died and the 
autopsy showed, as was suspected, a large thymus gland measuring two 
inches in length and one inch across. The lower pole of the gland com- 
pressed the large vessels in such a way as to cut off the circulation. 

A case of thymic tracheostenosis with substernal abscess was observed 
in a girl of two. The enlarged thymus gland could be mapped out by 
percussion. No improvement took place as regarded embarrassed respira- 
tion after administering mercuric inunctions and potassium iodide for about 
four weeks. Subsequently a rise of temperature was noted and the sub- 
sternal percussion dulness became more marked. An x ray picture showed 
a dense and a light shadow. Thymic enlargement and abscess formation 
were suspected and operative interference was decided upon. The child 
died under chloroform anaesthesia after the first few whiffs. The autopsy 
revealed a very large thymus gland and abscess. 

Treatment. — If enlargement of the thymus can be detected or is 
suspected calomel may be given in divided doses followed by a saline 
cathartic or potassium iodide (5ij ad 3j) may be administered by local 
inunction twice a day. In the event of an acute attack of suffocation, 
tracheotomy and intubation may be thought of. Resection of a part of an 
enlarged thymus gland and the removal of the entire gland has been done 
and the thymus has also been sutured to the sternum. 



DIPHTHERIA 



171 



ENLARGED BRONCHIAL LYMPH NODES 

The rational signs of enlarged bronchial lymph nodes are those of com- 
pression, i. e., pain, dyspnoea, cyanosis, and oedema, but all such character- 
istic signs may be absent, as the following case will show: A girl of four was 
admitted into a children's hospital with the diagnosis of bronchitis. There 
was no elevation of temperature, no pain, no dyspnoea, and the heart and 
kidneys were free. A few rales could be heard on auscultation over the 
sternum. On the morning following her admission she was playing with 
other children in the ward when she suddenly began to complain of pain 
in the neck, and almost immediately became cyanotic and asphyctic. As 
a large calibre O'Dwyer tube did not relieve her dyspnoea, a low tracheot- 
omy was performed also, without giving relief. The obstruction was 
evidently in the lungs, and she died in a few minutes. At the autopsy 
both bronchi were found plugged with a cheesy material which came from 
a tuberculous bronchial lymph node situated above the bifurcation of the 
trachea, which had perforated and ruptured into, the trachea. As long as 
the child was under our observation there were no symptoms pointing to 
such a condition, and the cheesy gland was in an unfavorable position 
for surgical interference. The specimen was presented to the American 
Pediatric Society at Washington, D. C, in May, 1900. When a diagnosis 
can be made, general hygienic management and the administration of 
potassium iodide are indicated. 

DIPHTHERIA 

INTRODUCTORY REMARKS 

Diphtheria is an acute infectious and contagious disease caused by the 
Klebs-Loeffier bacillus. The primary manifestations can be recognized 
at the portal of entrance in the nasopharynx or elsewhere. The secondary, 
or constitutional, symptoms are due to the absorption of toxines produced 
by the growth of microbes upon or within the mucous membrane, wherever 
lodged. The contagium is principally in the secretions from the nose and 
throat. For the method of preparing smears and glass preparations and 
swab cultures, see Laboratory Aids to Diagnosis. 

Diphtheria is communicable by direct or indirect contact as long as 
the bacilli are present in the various discharges from the throat, nose, ear, 
and other parts, and any unhealthy condition of the nose and throat pre- 
disposes to the infection. 

The incubation period varies, and it is possible for the germs to remain 
dormant in the mouth for an indefinite period and finally infect the body 
whenever the mucous membrane is weakened, receptive, or damaged. The 
formation of a pseudomembrane is the most constant lesion in diphtheria, 
but virulent infection may take place without membrane formation. 

The acceptance of the Klebs-Loeffier bacillus as the specific causative 
factor in diphtheria has made it necessary to give a name to membranous 
sore throat in which the bacilli are not found, but in which various cocci 



172 



PEDIATRICS 



are invariably present. This variety is at present called pseudodiphtheria; 
and some modern textbooks therefore speak of primary and secondary 
true diphtheria, and primary and secondary pseudodiphtheria. 1 Although 
the mortality of pseudodiphtheria is not so high as that of the Klebs- 
Loeffler variety, still it is a very dangerous disease, and may be followed by 
paralysis and death, and inasmuch as we cannot distinguish clinically one 
variety from the other, and inasmuch as valuable time is lost in waiting for 
a culture test — which, by the way, is not always conclusive or final — every 
attempt to adjust treatment in accordance with the bacteriological clas- 
sification must be looked upon as a failure in the present state of our 
knowledge. 

While fully cognizant of the scientific and practical value of bacterio- 
logical research, we must confess that failure to clear up doubtful cases 
by cultures, and in good time, is a daily occurrence. Moreover, it is well 
known that in localities in which diphtheria is endemic the majority of 



still, to wait even a few hours for a bacteriological diagnosis is not wise. 
The culture test should be looked upon as a confirmative one, and nothing 
more. In tuberculosis, gonorrhoea, malaria, etc., the microscope establishes 
a positive diagnosis, after which we may institute rational treatment, but 
in diphtheria our specific treatment comes first, the microscope afterward. 

Another point worthy of brief consideration is the difficulty of distin- 
guishing clinically between follicular tonsillitis and diphtheria. As recog- 
nized by Dr. A. Jacobi more than thirty years ago, no amount of experience 
will enable the physician to distinguish between the two affections. What 
looks like a tonsillitis to-day may be a virulent diphtheria to-morrow; such 
cases should be isolated and treated as diphtheria. If a subsequent exami- 
nation proves the contrary, no harm has been done. In practice, the phy- 
sician who acts in accordance with these views will have more success in 
the management of such cases than he who poses on an ultra-scientific 
pedestal, waits for the culture test in diphtheria, and writes death certificates. 

Clinical and Characteristic Varieties of Diphtheria. — Diphtheria runs 
its course as a mild case, a septic case, or a stenosis case; but we can never 

1 Another form of pseudodiphtheria is Vincent's angina with superficial and deep 
necrosis of tissue. 




Fig. 67. — Household Reflector. 
(From Paediatrics, 1901). 



cases eventually prove to be a 
mixed infection; consequently 
the physician will be wise to look 
upon all acute throat affections in 
children, attended with fever and 
swelling of the lymph nodes, or 
upon membranous rhinitis with- 
out fever, or upon hoarseness with 
slow progressive stenosis, as sus- 
picious of diphtheria, and treat 
them accordingly. The bacterio- 
logical diagnosis of diphtheria 
may be made in several hours 
by means of Loeffler's glucose 
blood serum and the incubator; 



DIPHTHERIA 



173 



determine at the onset whether a case will progress favorably or terminate 
fatally. Its characteristics are the formation of a membrane, the presence 
of fever, indurated lymph nodes in the neck, sepsis, and laryngeal steno- 
sis. In membranous rhinitis and membranous laryngitis there is usually 
no fever. 

The following clinical varieties will be met with in practice: 

1. So-called follicular tonsillitis. 

2. Primary diphtheria of the tonsils and pharynx. 

3. Primary nasopharyngeal diphtheria. 

4. Primary nasal diphtheria; also called membranous rhinitis, or 
diphtheria larvata. 

5. Primary laryngeal diphtheria (membranous croup). 

6. Diphtheria without membranes (simulating simple angina), and a 
virulent form without membranes. 

7. Secondary diphtheria, following measles, scarlet fever, pertussis, etc. 

8. Diphtheria in young infants. 

Symptoms and Diagnosis. — The onset may be gradual or sudden, 
with fever, vomiting, anorexia, foetid breath, pain, delirium, dysphagia, 
and tumefaction of the lymph nodes. The -membrane in true as well as in 
pseudodiphtheria presents many variations from a thick and cheesy, to 
a thin and veillike deposit; occasionally the surface appears as though 
smeared over with pus, and frequently we notice an infiltration of the 
mucosa without detachable membrane. The latter form may persist for 
weeks if antitoxine is not used, and if the local treatment is at all harsh 
and irritating. 

Virulent septic diphtheria without membranes, with very high fever, 
incessant vomiting, and a very rapid pulse, with or without delirium, is fatal. 
The throat is of a dusky brown red color. 

Diphtheria in the anterior nares gives very few symptoms: a running 
nose, excoriation at the nostrils, and snuffles, but no fever. This may go 
on for weeks, when an extension into the nasopharynx or larynx is manifest 
by other additional or subjective symptoms. The Germans call this form 
diphtheria larvata, and in all such cases a culture will show the true state 
of affairs. Ordinary thrush (Oidium albicans) can hardly be mistaken for 
diphtheria, but diphtheria of the mouth may be mistaken for stomatitis, and 
patches of leptothrix are frequently called diphtheria, particularly when 
associated with tonsillar inflammation, painful and swollen lymph nodes, 
and fever. Leptothrix patches will be found protruding from the crypts 
or margins of the tonsils, and are very difficult to scrape away; they also 
resist the action of various caustics to a remarkable degree, and sometimes 
make repeated scrapings and cauterization necessary. Mucosis of the 
uvula and palate may be mistaken for diphtheria and a bacteriological test 
will distinguish between diphtheria and the tonsillar ulcer of Vincent. 

Prophylaxis and Immunity. — Although the contagiousness of diph- 
theria is well established, it must be borne in mind that it is not so readily 
transmissible as scarlatina and some other infections. Moreover, that it 
can readily be prevented. At the present time the prevention of the spread 
of the disease is quite beyond the control of the central government. For 
information on municipal control, school hygiene, school inspection, isola- 



174 



PEDIATRICS 



tion hospitals, and general and local disinfection, the reader is referred to 
the various articles on prevention of the spread of contagious diseases in 
this book. 

Personal Prophylaxis and the Nasopharyngeal Toilet. — The 
proper management of the nasopharynx in children and adults is one of the 
most important subjects in practical medicine. The nasopharynx is the usual 
site of entrance of diphtheria, and to this locality the preventive measures 
must be directed. In a contribution to the proceedings of the New York 
Academy of Medicine in 1884 the writer showed that chronic nasal catarrh, 
adenoid vegetations, enlarged tonsils, and carious teeth favored diphtheria 
infection, and that in the absence of such conditions the instillation of a weak 
salt or alkaline solution into the nose morning and evening would prevent 
diphtheria in those exposed or prone to contract it. The general practitioner 
should see to it that in all children coming under his professional care 
adenoids, if present, are removed by the post-nasal forceps and curette, 
that hypertrophic tonsils are resected, and that carious temporary teeth are 
filled or extracted. 

The Nasopharyngeal Toilet consists in the instillation into each nos- 
tril, by means of an ordinary teaspoon, of a spoonful of salt water, 1 per 
cent, morning and evening (at bedtime and on rising), as the children lie on 
their backs, with the nose tilted up and the mouth open. The liquid does 
not wash through at once; some of it remains in the various recesses of 
the nasal cavity, and is eventually sneezed out or swallowed. In this way 
putrescible matter and bacteria are washed away (mechanical antisepsis). 
Where additional chemical antiseptic action is desired, a 1 to 5,000 mercuric 
bichloride solution, or Labarraque's solution, 10 per cent, or a rose colored 
permanganate of potassium solution should be employed. 

The nasopharyngeal toilet, carried out in the way described, is indicated 
for (1) all healthy children from one year up who live in infected localities, 
and (2) for all healthy children directly exposed to diphtheria infection. 
It is also the best method of local treatment in all cases of diphtheria, in which 
instances it should be resorted to every two hours; moreover, it is the most 
satisfactory local routine treatment in all diseases in which diphtheria fre- 
quently sets in as a complication, e. g., in scarlatina, measles, and pertussis; 
furthermore, it is a necessity before and after tonsillotomy and all operations 
on the nose and throat. This method is far superior to gargling, and in 
many forms of reflex cough, also in cough of tuberculous origin, it is far 
superior to nauseating expectorant mixtures, and in all forms of febrile 
disease in which the nasal secretion becomes dry, crusty, or hardened, 
half a teaspoonful of salt water instilled into each nostril affords much relief. 
The nasopharyngeal toilet not only does not provoke middle ear and acces- 
sory sinus complications, but, according to the experience of the writer, 
apparently prevents them. 

Immunity. — Specific and direct immunity is secured for those exposed 
to diphtheria by means of antitoxine. The period of immunity varies 
from three to six weeks, which is sufficient for all practical purposes in times 
of epidemics or house infection. Aside from the reports which come to 
us from abroad, we have reliable reports from various hospitals for the 
treatment of children's diseases throughout the country which go to prove 



DIPHTHERIA 



175 



the absolute value of antitoxine as an immunizing agent. The immunizing 
dose is 500 units, and all exposed children should receive this quantity. 

The curative and immunizing properties of diphtheria antitoxine are 
established facts. According to recent careful and unbiassed investigations, 
the mortality in primary diphtheria has been reduced two thirds, and the 
protective power of diphtheria antitoxine extends over a period of from 
three to six weeks or more. With an agent so powerful for good at our 
command, the question naturally arises: Do we or do we not make the 
best use of our new therapeutic acquisition ? The writer suggests 1 a new 
use for this agent by advocating an immunizing injection for young school 
children once or twice during the school year, for instance, in November 
and February, with the hope of preventing infection from primary diphtheria 
or croup, and, furthermore, with the hope of lessening the mortality of the 
severe forms of scarlatina and measles, a large percentage of such cases 
being complicated by diphtheria from the beginning or in the course of 
the disease. 

It is well known to the experienced medical practitioner that cases of 
scarlatina which show a complicating diphtheria from the onset are of a 
very grave type. In such cases we often observe an overwhelming sepsis 
with delirium and circulatory failure. In scarlatina with complicating 
diphtheria setting in after the first week the septic symptoms are never 
so acute and urgent. 

In measles we observe diphtheria as an early or late complication, but 
the most important diphtheria complication of measles is diphtheritic 
croup. The mortality from scarlet fever plus diphtheria and from measles 
plus diphtheria is quite high, and the writer is of the opinion, based on 
clinical experience, that this mortality can be markedly reduced by means 
of protective inoculations of diphtheria antitoxine. Such prophylactic 
management will have no effect upon pure and simple scarlatina or measles, 
but will certainly create more or less immunity as regards grave diphtheritic 
complications, or, in other words, turn a grave disease into a milder disease. 

Treatment. — (a) By antitoxine. (b) Supplementary treatment. 

(a) Antitoxine. Dosage. Indications for. 

The treatment for diphtheritic inflammation consists in the early 
and proper administration of reliable antitoxine, supplemented by the 
nasopharyngeal toilet. The time for discussing the pros and cons of anti- 
toxine treatment is past ; the specific curative power of this remedial agent 
is an established fact. Behring's contention, that if antitoxine is used early 
the mortality from diphtheria will not exceed 5 per cent, is borne out by 
the reports of competent clinicians all the world over. Opposition to any- 
thing so radically new as Behring's discovery is one of the associating features 
in the evolution of scientific medicine. Vaccination and antiseptic surgery 
stand in evidence of this fact. Any practitioner who studies the collective 
investigation reports for 1896 and 1897, on antitoxine for diphtheria and 
croup in private practice, issued by the American Psediatric Society, and 
fails to use antitoxine because he "does not believe in it," should not be 
entrusted with the management of a case of diphtheria, and the practitioner 



1 Transactions of the American Pediatric Society, 1903. 



176 



PEDIATRICS 



who thinks a case is mild and waits for severe symptoms before using 
antitoxine, utterly fails to grasp the situation and will frequently be 
disappointed. 

Indications for Antitoxine. — Antitoxine is indicated in doses of 500 
units for immunizing exposed persons, and in doses of from 2,000 to 4,000 
units to combat the disease. 

2,000 units for very young children. 
2,000 to 4,000 units for older children. 
3,000 units in croup cases. 

It should be employed at the earliest possible moment, and the dose 
repeated the following day and subsequently as often as is necessary. 
The dosage is expressed in units, and not in the serum quantity; the prepa- 
ration having the highest number of units in the least quantity of serum, 
and from an absolutely reliable source, is to be preferred. The injections 
are made in any region where a fold of skin can be picked up — the skin, 
the hands of the physician, and the syringe must be clean. Any syringe 
will answer, but the best syringe is one made entirely of glass, and it is 
now obtainable in the shops. 

The writer also advises the injection of a curative dose of antitoxine 
in every case of scarlet fever coming under his notice, because this disease 
is frequently complicated with diphtheria, and he also administers a cura- 
tive dose in cases of measles and whooping cough if the throat shows the slight- 
est appearance of a pseudomembranous patch. It would appear rational to 
give an immunizing dose in puerperal cases where a diphtheria case exists 
in the same house; also to children on whom an operation is to be done in 
the nose or throat and where the culture test shows the presence of diph- 
theria bacilli without clinical symptoms. Antitoxine is also indicated in 
diphtheria of the eye, which is, fortunately, very rare. The more common 
croupous conjunctivitis is not to be confounded with eye diphtheria, in 
which the eyelids are phlegmonous and hard. 

The antitoxine rash, which is noticed in a certain number of cases, 
has no very characteristic features and may readily be mistaken for scarlet 
fever or measles rash; its appearance is usually not heralded by a rise of 
temperature and increase of other symptoms. As regards the combined 
use of antistreptococcic and antidiphtheritic serums in cases of mixed infection, 
no positive advice can be formulated at the present time. 

(b) Local Supplementary Management. — The local treatment of diph- 
theria must be mild. Swabbing the throat in diphtheria is harmful, and 
should not be practised. Solutions used as gargles do not reach the naso- 
pharynx; the spray is only to be employed in cases in which force need not 
be used, e. g., in docile children. The best way to cleanse the nasopharynx 
is to pour the liquid into the nose from a spoon; if the nose is partly or 
almost completely stopped up, a blunt piston syringe or a Davidson's or 
fountain syringe must be employed. In septic cases the irrigation is best 
done as the children lie on the side, in order to avoid any tudden strain and 
collapse. For the majority of cases, instillation by means of a spoon will 
suffice. This may be done every hour or two, and if necessary day and 
night, according to the severity of the case. If syringes are used, the 



DIPHTHERIA 



177 



stream should be directed horizontally, and not upward. Syringes should 
not be used if bleeding follows each irrigation. 

The following liquids may be employed: Salt water, a teaspoonful to 
a pint, permanganate of potassium, a rose colored aqueous solution, mercuric 
bichloride in water, 1 to 10,000, listerine, 1 to 10, lime water, alum water, 
5 per cent, Labarraque's solution in water, 1 to 20, 2 per cent ichthyol 
solution in water. 

Peroxide of hydrogen has shown itself to be an active irritant, and 
aids the spread of diphtheria; it should therefore not be used in this disease 
unless largely diluted. Any of the above mentioned liquids may be used as 
a gargle when children are able to gargle. Excoriations at the angles of the 
mouth and at the nostrils usually heal under camphor ice. 

Antitoxine, with mild local treatment and judicious stimulation, will 
suffice for ordinary cases seen in good time; but as cases will come under 
observation in which valuable time has been lost in temporizing with house- 
hold remedies, the physician will not be spared the management of various 
complications, which will now engage our attention. 

Medication. — The local antiseptic power of a teaspoonful of medicine, 
as it glides over the tongue and down the oesophagus, is practically nil. 
The yellow chlorate of potassium and iron mixture and the mercuric 
bichloride mixture will not be necessary where antitoxine can be had, 
and should under no circumstances be given to a patient with an irritable 
stomach. As an aid to digestion the following mixture is efficacious: 

Py Ess. pepsin., gij ; 

Acid hydrochloric, dil., 5ss. 

M. S. : A teaspoonful four times a day. 

In septic cases, five drops of the tincture of chloride of iron may be given 
every four hours. 

Stimulation. — Whiskey, American Tokay wine, champagne, coffee, 
strychnine, gr. three times a day; camphor, gr. \ to 1, three times a 
day; benzoate of sodium and caffeine, dose, gr. 1. to 3, also subcutaneously, 
dissolved in water; camphorated oil, 5 to 15 drops, subcutaneously. When 
the stomach is irritable, stimulating drugs may be given subcutaneously 
or per rectum. 

Fever. — High temperature can be reduced by cold and lukewarm 
sponge and tub baths. (See General Therapeutics.) To give an antipyretic 
drug regularly every two or three hours is very bad practice; one or two 
doses in twenty-four hours, particularly at night, are serviceable. From 
3 to 10 grains of phenacetine with half a grain of caffeine, or lactophenin 
with caffeine in the same dose, may be given. Antipyrine is a safe anti- 
pyretic, and as it is soluble in water, from 3 to 7 grains may be given per 
rectum. In cerebral restlessness an ice cap is advisable. Quinine should 
never be given as an antipyretic in any but malarial disease. 

Vomiting. — In cases of incessant vomiting stop all internal medication 
and give only 1 to 2 drops of tincture of iodine in sweetened peppermint 
water every hour or two or wash out the stomach. 

Diarrhoea. — In many septic conditions a mild form of diarrhoea may 
complicate matters. This can usually be checked, if necessary, by a diet 
13 



178 



PEDIATRICS 



of burnt flour gruel or cornstarch pap and by omitting milk food for a time- 
Should this not suffice, 5 grains of tannic acid or tannigen, given with choco- 
late, or ^ a grain of acetate of lead with sugar of milk, or J a grain of 
camphor with \ of a grain of Dover's powder, will check the diarrhoea. 

Albuminuria and nephritis are frequent complications of diphtheria. 
A stiff dose of calomel and jalap, and one or two warm baths a day to pro- 
mote diaphoresis, will be the treatment in such conditions. In nephritis 
with dropsy, as a sequela of diphtheria, an infusion of digitalis may act as a 
diuretic by improving the circulation. 

Convulsions. — Initial convulsions indicate intense infection or nervous 
reflex irritability, for which an enema, a warm bath, and hydrate of chloral, 
gr. iij, and potassium bromide, gr. v, are indicated, per os or per rectum. 
Terminal convulsions, indicating heart failure and cerebral inanition, give 
an unfavorable prognosis. A warm bath and stimulants are here indi- 
cated: 5 drops of camphorated oil and 5 drops of ether subcutaneously 
every few hours. 

Dry Tongue. — The tongue is sometimes so hard and dry that pain 
and difficulty in swallowing result. For this condition glycerine and rose 
water, equal parts, applied with a brush, afford relief. 

Pseudomembranous conjunctivitis is occasionally seen in severe 
diphtheria cases. This readily yields to ice compresses and the boric acid 
spray. In true diphtheria of the eye, in which the eyelids are much swollen 
and indurated, antitoxine must be used in large doses. Fortunately, 
as has already been said, this condition is very rare. 

Otitis media, due to an extension of the septic process through the 
Eustachian tube, is frequently observed, but the earache is not nearly 
so intense as in ordinary otitis media, and rupture of the drumhead takes 
place readily. The ear should be cleansed with mercuric bichloride solution, 
1 to 5,000, or a warm boric acid solution with cocaine, or menthol in sweet 
almond oil (31 to 3jv) should be instilled. The drum membrane may 
require puncture. 

Hemorrhage from sloughing of the tissues is a very dangerous and 
distressing complication. If possible, the bleeding spot should be located 
by means of a strong light and directly cauterized with the actual cautery, 
lunar caustic, chloride of zinc, alum solution, or antipyrine and tannin. 
The styptic iron preparations are not so applicable, on account of the large 
grumous blood clots which invariably form. 

Phlegmon and induration of the tissues op the neck, with indis- 
tinct fluctuation of cervical lymph nodes, are best managed by a large 
incision through the entire dense and thick skin down to the glands. The 
latter are usually in a friable, spongy state with little pus spots scattered 
through the tissue, and can readily be broken up by pushing a blunt director 
or dressing forceps through the capsule and sweeping it around in various 
directions in order to break up the necrotic tissue. Make one abscess 
cavity which can readily be drained by means of iodoform or bichloride 
gauze under a moist dressing. The neighborhood of such a diphtheritic 
and gangrenous wound occasionally has an erysipelatous appearance, 
which usually subsides under the application of cold lead lotion. 



croit 



179 



Paralysis and Ataxia Following Diphtheria 

Postdiphtheritic paralysis may affect the general nervous system, the 
eye, ear, throat, etc. 

Paralysis of the soft palate is not rare. A stationary palate, a na:al voice, 
and food regurgitation through the nose are the characteristic symptoms. 
For this condition, as well as for the temporary locomotor ataxia which is 
occasionally observed, we require fresh air, baths, massage, the interrupted 
current, and -gV of a grain of strychnine, three times a day, by the mouth 
or under the skin. The antitoxine treatment has not made paralysis cases 
more frequent, nor does it appear to facilitate the recovery from such 
complications. A gradual paralysis of the respiratory muscles, including 
the diaphragm, as shown by a weak cry and rapid, superficial breathing, 
is a very serious condition to deal with, but may improve under stimulation 
and artificial respiration. 

In addition to the general treatment just announced, the cold douche 
and artificial respiration may do good. Cardiac arrhythmia in the wake of 
infectious disease is not infrequent and is mostly due to myocardial involve- 
ment, for which rest, hygiene, and rational diet and stimulation are to be 
employed. Sudden death from heart paralysis gives no chance for treatment. 
In all cases of septic diphtheria, early and proper stimulation may prevent it. 

The anaemia which is known to follow in the wake of diphtheria and other 
infectious diseases demands tonics, such as fresh air and iron. Broncho- 
pneumonia and lobar pneumonia, thrombosis of veins and arteries, and other 
remoter complications will come under observation, and will call for proper 
management. 

Diet. — Milk, Vichy, matzoon, kumyss, beef peptonoids, cornstarch, 
eggnog, custard, ice water, cream, farina, cocoa, eggs, raw meat, burnt 
flour soup, whiskey, California Tokay, coffee, tea, punch, iced champagne, 
pineapple juice, and tropon. The diet in diphtheria is of prime importance. 
The food should be nutritious and digestible. Forced feeding is proper 
in exceptional cases, but it is well to remember that children with febrile 
and septic disease have little desire for food, and that the stomach will 
resent all attempts at overfeeding. Somatose is soluble meat without taste 
or smell, and can be given with cocoa, milk, gruel, rice, etc. 

For rectal alimentation we inject a mixture of whiskey, egg yolk, beef 
peptonoids, and warm water or somatose in oil emulsion. 

Gavage will be indicated in exceptional cases. 

In regard to the question as to when it will be safe to send children 
who have had diphtheria back to school, we should judge, by the culture 
test. Whenever this test cannot be employed we should wait at least 
three weeks from the disappearance of clinical symptoms, during which 
time the nasopharyngeal toilet should be diligently carried out. 

CROUP 

In practice we recognize (1) a croupy cough without stenosis; (2) a 
catarrhal or pseudocroup with dyspnoea, and (3) true croup, in which the 
stenosis is progressive and frequently necessitates operative interference. 




Fig. 68. — Intubation Tube in Situ. (Skiagram.) 



CROUP 



181 



The croupy cough is common in children with adenoid vegetations, follicular 
pharyngitis, or large tonsils; it usually begins at night and yields to the 
mildest treatment. A cloth wrung out of cold water, around the neck, 
salt water dropped into the nostrils, and a hot drink are all that is necessary 
for the time being, with subsequent curettage or cauterization of the swollen 
follicles in the pharynx. Emetics are not indicated, although very popular 
with that class of parents who delight in goose grease and turpentine. 

As a type of pseudocroup with dyspnoea, the croup of measles is character- 
istic. Here we have to deal with catarrhal laryngitis or oedema of the glottis, 
which rarely goes on to complete stenosis ; the treatment is the same as for 
"croupy cough." Only in extreme cases will local scarification of the 
cedematous tissues or intubation be necessary. Adrenalin chloride is 
capable of controlling oedema. It may be applied by means of a cotton 
applicator every hour. The so called true croup either is a primary mem- 
branous laryngitis or is secondary to diphtheria of the nasopharynx. In 
primary membranous croup the pharynx is pale end the temperature normal, 
and the onset is never sudden; hoarseness, aphonia, and stenosis come on 
gradually, whereas in pseudocroup the onset is generally sudden, the pharynx 
is usually congested, and there is fever. About 80 per cent of membranous 
croup cases are known to be cases of Klebs-Loeffler diphtheria; in about 
20 per cent this bacillus has not been found. True croup should, therefore, 
be quarantined as diphtheria. 

The secondary croup with stenosis is due either to an extension of the 
membranes downward or to the swelling and oedema of the tissues adjoining 
a diphtheritic patch. Urgent laryngeal stenosis, secondary to various forms 
of nose and pharynx diphtheria, is, therefore, not necessarily membranous, 
but the treatment is practically the same in both instances. 

Treatment of Croup with Urgent Stenosis. — Before the advent of anti- 
toxine the best treatment for true croup, before operation, was with mer- 
cury or calomel, internally, by inunction, or by fumigation, and it is well 
known to experienced physicians that intubation and tracheotomy gave 
better results when mercury had been administered. Mercuric bichlo- 
ride, gr. -jV, was given every hour for one or two days, or 20 grains of 
calomel were volatilized over a lamp, under an improvised tent, every 
three hours for from twenty-four to forty-eight hours. The spray and 
croup kettle have very little value, and emetics in any shape are productive 
of evil, as they sap the strength of the patient. Now that we have specific 
treatment, we shall not discuss in detail our former management of croup 
cases, because the best treatment of croup, before operation, can be men- 
tioned in one word — antitoxine. Here, again, I refer the skeptic to the report 
of the American Pediatric Society on laryngeal stenosis, which tells the 
whole story, reflecting, as it does, the experience of hundreds of physicians 
and sifting the evidence in a judicial manner. Briefly, the report says: 
Before the use of antitoxine 27 per cent of intubation patients recovered; 
now 73 per cent recover. Sixty per cent of stenosis cases do not require 
operation if antitoxine is used in time, and an early use of antitoxine will 
lower the mortality of intubation cases still more. 

In every case of acute progressive stenosis 2,000 to 3,000 units of diph- 
theria antitoxine should be administered at once, and the dose may be 




182 



Kig. 69. — Intubation Tube in Situ. (Skiagram.) 



INTUBATION AND TRACHEOTOMY 



183 



repeated in from twelve to twenty-four hours, and so on, until relief is 
manifest. As soon as the stenosis becomes less urgent, and the cough 
somewhat loose, the main danger is over, and camphor, gr. or spir. am- 
monite, aromat., gtt. x, may be given as an expectorant and stimulant, 
four times a day. The same management should be resorted to in secondary 
stenosis following scarlet fever, measles, pertussis, nasopharyngeal diph- 
theria, or so called tonsillitis, together with the nasopharyngeal toilet, as 
before described. When antitoxine fails to check a progressive stenosis, 
the time for operative interference is close at hand. The proper time for 
the operation is a matter of experience; the physician should not wait until 
the patient is cyanosed and the pulse intermittent. 

INTUBATION AND TRACHEOTOMY 

Intubation is the art of introducing tubes into the larynx and removing 
them at the proper time. In combination with antitoxine, intubation is 
one of the greatest blessings at the disposal of the physician. Dr. J. 




Fig. 70. — O'Dwyer's Intubation Set. 



O'Dwyer, of New York, is the inventor of our present method of tubing for 
croup. The instruments he devised have been in general use since 1886, 
and although a number of modifications have been suggested, none has 
come to the writer's knowledge which is in any respect an improvement 
on those used in the original method, with the exception of Denhard's 
gag, which is universally used. Many of the modifications are useless 
or bad. The tubes now in use have a smooth coating of hard rubber, to 
prevent incrustation. The operation of intubation and extubation is not, 
in itself, difficult; but every one contemplating becoming a safe operator 



184 



PEDIATRICS 



should practise the operation on the cadaver. Its modus operandi cannot 
be learned from reading. Colleagues with a short and thick index finger 
have some difficulty in learning to tube properly. 

How to Operate. — Remove the child's clothes, except the undershirt, 
and wrap the child securely in a towel from the shoulder down, secured 
by safety pins. Place the child upright, facing the operator, in the lap of 
the nurse, who sits upright in a common straight backed chair. The arms 
of the patient are to be firmly held below the elbow; the child's legs are 
clasped between the knees of the nurse. The assistant stands behind the 
chair, holds the child's head firmly between the palms of his hands, and when 
the gag is inserted includes it within his firm grasp. The position of the 
child should be as though it hung from the top of its head. The operator 
now inserts his index finger, hooks up the epiglottis, and inserts the tube 




Fig. 71. — O'Dwyer's Intubation Instruments. 



in the funnel-shaped entrance to the larynx by elevating the handle of the 
introducer. The tube is then gently pushed home. While loosening and 
withdrawing the obturator, the head of the tube is held in place by the tip 
of the index finger in the throat, and a gentle push may be given to place 
the tube well into the larynx. The introducer must be kept in the middle 
line, and the child must not be allowed to slip down in the nurse's lap. 



INTUBATION AND TRACHEOTOMY 



185 



The gag must be properly adjusted and firmly held. Any carelessness in 
carrying out these details will result in failure to introduce the tube. 

It may be in place to dwell briefly upon some important points as re- 
gards feeding and medication, duration of wearing the tube, intermittent in- 
tubation, the management of cases where the tubes have been coughed up, 
secondary stenosis from cicatrix, granulations , or ixdema, the select on of special 




Fig. 74. Fig. 75. 

Figs. 72-75. — Technique of Intubation (after Trumpp). 



tubes for aidema of the epiglottis and venticular bands, retained tubes, etc. A 
new tube should be used for each case. If the operator is in doubt as to 
the proper size, the smaller size should be chosen. The tube may be dis- 
infected immediately before using, and a minute quantity of iodoform oint- 
ment may be used as a lubricant. When the tube is in the larynx, and not 
blocked by detached membranes, a characteristic moist rattle will be heard 
as the air is forced in and out in respiration. Before removing the gag, 
the left index finger is rapidly passed to the head of the tube to determine 
positively that the tube is in its proper place, then the string and finally 
the gag are removed. It is best not to use a string which is too strong to 
be broken, for in case it should become wedged in its eyelet, the string 
may be broken away with the index finger at the head of the tube to prevent 
dislodgement. If a detached membrane has been forced down, the child 
will become more cyanotic, whereupon the tube should be pulled out by 
its string and reintroduced after the detached membrane has been expelled 
by coughing. If a tube is coughed up after having been in the larynx a 
day or two, a reintroduction is not necessary until urgent symptoms 



186 



PEDIATRICS 



demand it, and if a child has great difficulty in swallowing food, the tube 
may, in exceptional cases, be taken out once a day for the purpose of proper 
feeding. 

Feeding. — Some children will swallow liquids without difficulty, others 
will swallow semisolids best, such as custard, scraped meat, ice cream, 
sponge cake soaked in milk, hard yolk of egg, farina with egg, somatose, 
matzoon, or ice. Most children will swallow well in the dorsal-horizontal 
posture. Forced feeding by means of a tube (gavage) may become 

necessary, the tube being in- 




troduced through the nose or 
mouth. (See Gavage.) 

Medication. — Stimulants, 
heart tonics, and antipyretics 
can be given with the food or 
subcutaneously or per rectum. 
Tubes may be removed after 
two, four, or six days. Anti- 
toxine has shortened this 
period very much. When it is 
noticed that a greenish muco- 
pus is coughed up through the 
tube, it is time to remove it. 
To avoid pressure necrosis, a 
tube should not remain longer 
than six days. A moderate 
secondary stenosis after the 
removal of a tube may be re- 
lieved by a few five-grain doses 
of antipyrine. 

How to Remove the Tube. 
— Place the child in the posi- 
tion for intubation, as described 
above. Thrust the left index 



Fig. 76.— Intubation of the Lakynx. finger past the epiglottis, hook 

it up, and with the tip of the 
finger as a guide introduce the extractor tip into the tube lumen and get 
a firm hold on the tube by depressing the handle. The tube is raised 
sufficiently to get the tip of the index finger under its head, and by this 
combined manipulation the tube is lifted out of the larynx and out of 
the mouth. In introducing, stand before the patient; in extracting, sit 
before the patient. After removing a tube, it is desirable to be within 
easy call for some time, as some cases need re-intubation even after twelve 
to twenty-four hours. If re-intubation is not necessary within one hour, 
the operator may leave the patient, but be within easy call. 

Retained Intubation Tubes. — Apart from ordinary "prolonged tube 
cases," a stenosis which occasionally persists in intubation cases is usu- 
ally the result of traumatism, i. e., laceration during attempts at intuba- 
tion, and pressure necrosis from badly constructed tubes that have been 
too long in the larynx and become roughened by calcareous deposit. Cica- 



INTUBATION AND TRACHEOTOMY 



187 



tricial stenosis or granulations will be found at the entrance of the larynx 
at the base of the epiglottis. Such cases require expert management, and 
each case will need its own treatment. Hard rubber tubes for long wear 
and built up tubes with extra large heads and large retaining swell are called 
for. Accessible granulations may be removed, and superficial granulations 
may be attacked by coating the tubes with gelatin and alum or tannin, 
as suggested by O'Dwyer. In some cases, but rarely, tracheotomy must 
be done, with subsequent local treatment and dilatation. Specially built 
up tubes are also used when swollen tissue overrides the head of the ordinary 
tubes in primary intubation. As a dernier resort resection of the constricted 
portion of the larynx or trachea has been performed. 

Secondary stenosis, after intubation, due to abductor paralysis, has been 
reported, but lacks confirmation. Secondary stenosis or persistent hoarse- 
ness with moderate stenosis may be due to ankylosis of the crico-arytsenoid 
articulation, which may follow any local inflammatory process. Vibratory 
massage would be applicable to such conditions. Antitoxine and intubation 
combined have given such brilliant results in croup that primary trache- 
otomy is now rarely performed in this country for diphtheritic stenosis. 
A rapid tracheotomy may become necessary if, in the act of tubing, the 
stenosis should suddenly become complete. This accident has happened 




Fig. 77. — Intubation Statistics of Budapest Stephanie Children's Hospital. 

Serum period represented by thick line . Mortality represented by the interspace 

between two lines. (Prof. Bokay.) 



to the writer in tubing an adult for stenosis of several weeks' standing 
and of unknown origin. The tube struck a subglottic vascular new growth, 
which bled freely into the bronchi. A rapid tracheotomy was performed 
and the haemorrhage fortunately arrested, the patient making a complete 
recovery. Intubation in the adult is a difficult and rather unsatisfactory 
procedure. In diphtheria cases with great swelling of the tonsils, of the 
uvula, and at the entrance to the larynx, tracheotomy would probably be 
the most satisfactory operation. 

Tracheotomy is not a difficult operation, but is, as a rule, an unpleasant 
one in private practice. In performing the operation the surgeon is usually 
fortunate if one trustworthy assistant is at hand, who is expected to 



188 



PAEDIATRICS 



administer the anaesthetic and assist at the wound as well. Now, if the patient 
is in any way troublesome, as is frequently the case, the operator may not 
be able to proceed with the necessary ease and facility. In such a case 
he author's automatic retractor will be of service; it will keep the edges of 
the wound well apart, it may be hooked into the fascia as the several layers 
are divided, it will hold aside such blood vessels as are in the way of the knife, 
and may finally be hooked into the edges of the tracheal wound, the trachea 




Fig. 78. — Larynx of Child Two and a half Years Old. 

Showing ulceration caused by too large a tube. The ulceration at a involves the whole thick- 
ness of the cartilage. Those at b and c are mere abrasions. (Dr. M. Nicoll, Jr.) 

may be examined at lei ure, and there need be no haste in getting the tube 
into its place. 

The instrument, devised many years ago, consists of a rubber band 
to each end of which is attached a curved double hook of nickel plated 
steel. It can be used as a general retractor in operations requiring careful 
dissection in different parts of the body; but it is especially applicable 
to the neck. 

The instrument can be disinfected and the rubber must be renewed 
occasionally. 

With a bottle, wrapped up in toweling to act as an appropriate support 
at the nape of the neck, and the child under chloroform, an incision is made 
about two inches long, from the superior border of the thyreoid cartilage 



INTUBATION AND TRACHEOTOMY 



189 




LATIONS. 



downward. The best guide is the cricoid ring, which is the most prominent 
part to be felt in children. After the skin has been incised, the superficial 
fascia is divided on a director, and the presenting 
veins are held aside by means of the author's re- 
tractor. To get at the three upper tracheal rings 
above the thyreoid isthmus, we make a transverse 
incision into the deep fascia where it is inserted into 
the cricoid cartilage (Boze's point). This done, the 
deep fascia, and with it the isthmus of the thyreoid 
gland, can be pushed downward with any blunt in- 
strument, and enough space gained to open the tra- 
chea. The trachea can also readily be reached below 
the isthmus of the gland by means of blunt prepara- 
tion and by the aid of the automatic retractor, little 
else but fat and dilated veins presenting themselves 
in this region. In opening the trachea we cut from 
below upward, and do not plunge the knife into the 
trachea with any force, so as to avoid injury to the 
posterior tracheal wall. After the membranes and 
secretions have been expelled by coughing, the tube 
is introduced and secured by a tape around the neck. 

The tube is removed at least once a day and cleansed, and should not be 
discarded until the patient is able to breathe for days with the inner tube 

out and the outer tube closed 
with a cork. 

To cleanse the tracheotomy 
wound with the tube in situ, 
the writer attaches a rubber 
tube six inches long to the tra- 
cheotomy tube, and uses a 
strong spray of any desirable 
antiseptic solution ; the attached 
rubber tube prevents the spray 
fluid from entering the trachea, 
and permits breathing at the 
same time. When there is 
much difficulty in expectorating 
the secretions, a few drops of 
salt water occasionally dropped 
into the trachea through the 
tube will facilitate their expul- 
sion. Feeding and medication 
present no difficulties. Sec- 
ondary granulations are excised 
or cauterized, and intubation may be done to discard a tracheotomy tube 
in difficult " decanulement." 




Fig. 



80. — Author's Automatic 
Retractor. 



Tracheal 



ISO 



PAEDIATRICS 



Disinfection of the Sick Room. See also article on Disinfection 

The general principles involved in the prevention of infectious disease 
are not complex: 

1. Isolation of the patient, and avoidance of the sick room. 

2. Disinfection of rooms and their contents by steam or chemicals 
or by cleanliness and sunshine; personal disinfection and prophylaxis, 
including fortifying the system. 

3. Ventilation to prevent concentration of poisonous matter. 

The management of diphtheria and scarlet fever in a private house 
according to these principles is not difficult. The patient is isolated in a 
clean room, bare of all but the necessary furniture. A hall bedroom or one 




Fig. 81. — Cleansing Tracheotomy Wound with Tube in Situ. (Author's method.) 



on the top floor is to be preferred. In some instances it may be advisable 
to keep the patient in the ordinary bedroom occupied at the time of being 
taken sick, and quarantine, in the best manner possible, this floor of the 
house already infected. The well children are to be kept from school and 
church. Where the intercourse of parents with a sick child cannot be 
avoided, even when trained nurses are employed, it may become necessary 
to isolate the well children. Food and drink not consumed by the patient 
must be burned or disinfected in a slop jar holding a chlorinated soda 
solution. Dishes should be rinsed in soda solution, 5 per cent, and a subli- 
mated solution 1 to 1,000, before returning them to the kitchen. As dried 
sputa are liable to be spread through the air, all expectorated matter 
should be received into rags or paper spittoons, which are to be burned, 



TONSILLITIS, PERITONSILLITIS, QUINSY 



191 



or into a jar holding a sublimate solution, 1 to 1,000. The sick room 
should not be swept with a broom, to avoid raising dust. For cleaning 
purposes, employ moist rags, which are to be burned. Urinals, bed pans, 
and faeces are treated with quicklime, bichloride solution, 1 to 1,000, or 
Labarraque's solution. 

The nurse should not eat or drink in the same room with the patient, 
and before going to meals she should clean her hands and arms with green 
soap and sublimate solution, 1 to 1,000, and put on a clean, long, loose 
gown, which hangs outside of the sick room. During the period of desqua- 
mation the patient should receive a daily bath of tepid water containing 
green soap. At the termination of a case the nurse takes a bichloride bath, 
1 to 2,000, and washes her hair with the same solution. In case of death, 
the body is to be wrapped up at once in a bed sheet soaked in mercuric 
bichloride solution, 1 to 1,000, and no public funeral is to be permitted. 
The sick room and all objects in it must be disinfected. Hard finish or 
painted walls and ceilings and floors may be washed or sprayed with dis- 
infecting fluids. Papered walls may be rubbed down with a damp cloth 
or bread crumbs; or, better still, the paper should be removed. A fresh 
coat of kalsomine or whitewash is advisable wherever it can be applied. 
After disinfection, the windows must be kept open day and night for several 
days. Carpets, upholstered furniture, and other articles can be disinfected 
by steam through the health board or at private disinfecting plants. 

Recently formalin vapor has been extensively used for disinfecting 
sick rooms and their contents, and, as far as my experience goes, I consider 
it to be a powerful disinfectant, far superior to sulphur. Formalin vapor 
is generated in an apparatus which permits the gas to be discharged by 
means of a tube through the keyhole into a room which is otherwise tightly 
closed. 

TONSILLITIS, PERITONSILLITIS; QUINSY 

The ordinary clinical variations of acute tonsillar inflammation are: 

1. Follicular tonsillitis (non-diphtheritic). 

2. Croupous tonsillitis ) , .,. , , , 

tti 7 , ■„ •, ■ > pseudodiphthena. 

3. U Icero-memoranous tonsillitis ) L 1 

4. Diphtheritic tonsillitis. 

No amount of experience will enable us to distinguish clinically between 
1, 2, 3, and 4 in any locality in which diphtheria is endemic. What looks 
like tonsillitis to-day may be diphtheria to-morrow. Such cases must be 
isolated and treated like diphtheria; if a subsequent examination proves 
the contrary, no harm has been done. The so called pseudodiphtheria 
kills children as well as the Klebs-Loemer variety. In this field the value 
of bacteriological examinations as practised in large cities has been over- 
estimated. In country districts in which diphtheria is not endemic and 
in immunized children in the city we see cases of undoubted acute fol- 
licular tonsillitis, but there are no reliable differential points. At the bed- 
side in acute sore throat cases, clinical observation goes before laboratory 
statistics, and a report "No diphtheria bacilli found" should influence 
the practitioner but very little, if at all, in the subsequent management 
of a case. 



192 



PEDIATRICS 



Differential Points. — Syphilis, leptothrix, and other rare parasitic affec- 
tions of the tonsils; are not liable to be confounded with diphtheria, 
pseudodiphtheria, or tonsillitis. Membranous and ulcerative lesions of 
the mouth and throat may be due to the spirillum of Vincent (diphtheroid 
angina). Such deposits gradually disappear after mild local antiseptic 
treatment. 

Symptoms. — The symptoms of tonsillitis are fever, general malaise, 
vomiting, pain on swallowing, and noisy respiration. The tonsil is red and 
swollen; the lymph nodes are swollen; the tongue is coated. In follicular 
tonsillitis a punctate, cheesy deposit protrudes from the crypts of the tonsil. 

Treatment. — A child afflicted with so called tonsillitis should be isolated 
and should receive a warm bath and a laxative or an enema, and should be 
put to bed. A cool compress may be placed around the neck, and over this 
a flannel bandage. The compress may be renewed every hour or two, or 
an ice poultice may be put around the throat (ice and sawdust wrapped in 
oiled silk). 

The child should receive cooling drinks and a liquid diet. (See Fever 
Diet.) Salt water should be dropped into each nostril every two to three 
hours. (See Nasopharyngeal Toilet.) 

Internally the following prescription may be administered: 

Ijs Tinct. iodini, gtt. x; 



M. Sig. : A teaspoonful every hour. 

Older children may have cracked ice to swallow, and gargle with chlorate 
of potassium solution (2 per cent). The prognosis is favorable. 

It must be emphasized, however, that in all centres of population in 
which diphtheria is endemic even a simple tonsillitis must be looked upon 
with suspicion, and at the first sign of a cheesy or membranous deposit, 
be it punctate or not, a curative dose of diphtheria antitoxine (2,000 to 
4,000 units) should be administered to children in order to be on the safe 
side as regards further development. 

Phlegmonous Tonsillitis, or Quinsy. — The jaws become stiff, and the 
mouth is opened with difficulty. Swallowing is very difficult; food re- 
gurgitates through the nose; the voice has a nasal character; fever and 
constitutional disturbances are marked; and there may be hoarseness or 
noisy respiration. 

Treatment. — Is the same as in the mild variety. Children should re- 
ceive 2,000 units of antitoxine. If cold applications are not tolerated, a 
hot poultioe or hot water bag may be applied. Early incision of a pointing 
abscess or fluctuating soft area, with or without local anaesthesia, is of the 
utmost importance on account of the danger of cedema of the glottis and 
death from suffocation. Surgical interference from without through the 
skin is often necessary under general anaesthesia, in order to relieve tension 
when deep tissues are involved. In the severe and dangerous form known 
as angina Ludovici the tissues of the neck present tense induration, and a 
fatal termination is the rule unless good and timely surgical interference is 
at hand. 



Aquae menth. pip 
Syr. simplicis, . . . 




HYPERTROPHIC TONSILS IN CHILDREN 



193 



HYPERTROPHIC TONSILS IN CHILDREN 



Enlarged tonsils obstruct the posterior nares and are a prolific source 
of nasal and aural disease. They are frequently found associated with 
adenoid A'egetations in the vault of the pharynx. 

Symptoms. — Nasal voice, reflex cough, noisy respiration, peculiar facial 
expression, mouth breathing, snoring at night, deafness, and restlessness in 
sleep. 

Enlarged tonsils are usually the product of repeated attacks of tonsillitis, 
and have in themselves a tendency to acute inflammation. Inflamed tonsils 
are a source of 
danger to the in- 
dividual, as they 
appear to favor 
systemic septic in- 
fection, with subsequent localization in vital organs 
(endocarditis and myocarditis) . As a portal of entrance 
for infection, however, the inflamed or enlarged tonsil is 
of minor importance as compared with the retropharynx 
in a state of inflammation or irritation. 

Treatment. — The reduction of enlarged tonsils in 
children is best accomplished by means of the tonsillo- 
tome, at one sitting. The use of the tonsil knife and 
cutting forceps for the purpose of slitting up the crypts 
and removing tissue piecemeal is more adapted for work 
upon adults. The Tiemann-Fahnenstock or MacKenzie 
tonsillotome, is perhaps the handiest instrument to use 
in connection with the intubation gag. The tonsillo- 
tome will remove a tonsil which can be engaged in its 
ring. Tonsils which are fixed by adhesion to the an- 
terior pillar of the soft palate cannot as a rule be en- 
gaged by the tonsillotome blade until the adhesions 
have been loosened so that the tonsil may protrude 
trophic tonsils extending low down in the pharynx also present diffi 
culties in the way of removal. The tonsillotome may have to be applied 
twice to the same side. In many instances the removal of the upper, 
greater portion of the tonsil will relieve the symptoms on account of which 
the operation was done. Soft, friable tonsils are apt to be crushed by a 
blunt ring knife and may require subsequent trimming with curved blunt 
pointed scissors. Anaesthesia in tonsillotomy is not absolutely necessary. 
If the parents of children request an operation under anaesthesia, ether is 
perhaps the safest anaesthetic, all things considered, and the narcosis need 
not be deep. The tonsillotome should be sterilized by boiling in a weak 
soda solution, and if there is time the nasopharyngeal toilet should be em- 
ployed for a few days prior to the operation. If one is compelled to operate 
during an epidemic of diphtheria, a prophylactic dose of antitoxine is in 
order. 

After-treatment and Sequelae. — After the tonsils are out, the parent is 
told that the child may vomit dark blood which it has swallowed, and that 
14 



Fig. 82. — McKenzib 
Tonsillotome. 

Elongated hyper- 



194 



PEDIATRICS 



a fresh haemorrhage should be reported at once. The patient must have only 
soft or liquid food for a few days, and the nasopharyngeal toilet should be 
practised. Older children will gargle in addition. 

The formation of a pseudomembrane on the wound made by the ton- 
sillotome is frequently observed, with and without constitutional symptoms 




Fig. 83. — Tiemann-Fahnenstock Tonsillotome. 



(fever). This may be due to an unclean instrument, an unclean throat, 
or both. 

Dangerous haemorrhage after tonsillotomy is rare in children unless 
they have the so called hgemorrhagic diathesis. Bleeding may be controlled 
by ice or alum solution (both should be at hand) , and digital pressure with 
the thumb can be kept up for hours if necessary. If bleeding cannot be 
controlled by such means or by the actual cautery, the external carotid 
will have to be ligated. 

It is best, all things considered, not to remove the tonsil completely, 
but to leave a small stump which could be grasped by a forceps for the pur- 
pose of controlling severe haemorrhage. The teaching that a tonsillotomy 



^ „ — - =1 

Fig. 84. — Tonsil Knife (Douglas). 

is a failure unless the tonsil is completely removed is not in harmony with 
the experience of the writer. Tonsils and adenoids can be removed at one 
sitting under ether anaesthesia. 

ADENOID GROWTHS AND THEIR REMOVAL 

Adenoid vegetations are common in children and give rise to excessive 
discharge of mucopus, with reflex cough. The character of the voice is 
altered, and mouth breathing is the rule. The presence of adenoids often 



ADENOID GROWTHS AND THEIR REMOVAL 



195 



causes ear symptoms (pain and chronic otitis), and bed wetting is frequently 
observed in children with nasal obstruction. A positive diagnosis is readily 
made by a digital exploration with the index finger, nail side up. The 




Fig. 85. — Beckmann's Curette for Adenoids. 



growths are of a soft, pulpy consistence — in some cases the growths are firm 
and feel like a bunch of worms. 

Local medication will not effect a radical cure, which can only be ac- 
complished by extirpation of the growths. The operation can be performed 
without an anaesthetic or under ether narcosis. The patient is firmly held 




Fig. 86. — Post Nasal Fenestrated Forceps for Adenoids. 

in an upright position and the mouth held open by mouth gag (intubation 
gag). A properly curved fenestrated post nasal forceps is inserted behind 
the soft palate into the vault of the pharynx; the branches of the instrument 
are opened and then closed, whereupon the instrument is removed, carrying 
with it as much of the growth as has been caught within its branches. 
A Beckmann curette is now inserted in the same way, and by dexterous 




Fig. 87. — Adenoids Before Operation. Fig. 88. — Adenoids After Operation. 

(Dr. French.) (Di. French.) 



manipulation the remaining adenoids are planed off. The removal of a 
portion of the growth with forceps is mainly for the purpose of demon- 
strating to the parents of children the nature of the trouble. The brisk 



196 



PEDIATRICS 



haemorrhage following the operation usually stops promptly, or alum water 
may be dropped into the nostrils as a styptic. If performed under an anaes- 
thetic, the position of the head must be such as to avoid asphyxia from 
flow of blood into the trachea. 

Removal of Adenoids and Tonsils under Ether. — Chloroform as an an- 
aesthetic appears extra hazardous to those having a lymphoid tendency. 

After the child is anaesthetized (the head being de- 
pendent over the edge of the table and supported 
by the assistant), the jaws are held open with a mouth 
gag, the forceps is introduced, and all tissue within 
its grasp is removed. Then the curette is used, and 
the finger may sweep all over the postnasal space to 
detach loose tissue with the nail. The patient is 
turned over on his face and the blood allowed to 
flow out, the nose and throat are well sprayed with 
an iced antiseptic solution, and the operation is fin- 
ished. The patient is now placed in bed, the direc- 
tions are given for a soft diet, and a spray of the iced 
antiseptic solution in the nose and throat is used 
once every two hours. On the following day the 
patient may be up and about. In operating for phi- 
mosis, adenoids and enlarged tonsils if present can be 
removed before the pa- 
tient is out of his nar- 
cosis, and vice versa. 

In severe haemorrhage 
following the operation 
a tampon saturated with 
alum water may be 
the nasopharynx, as in 




Fig. 89. — Adenoids 
Before Operation. 



firmly wedged into 
nasal haemorrhage. 

Possible and Avoidable Traumatism 
During Operations for Adenoids. — Trau- 
matism of the soft palate; injury to the pos- 
terior border of the septum; injury to the 
pharyngeal wall in extreme curvature of the 
cervical vertebra?. 

Morbid Conditions Simulating Adenoids to 
Account for the Persistence of Symptoms after 
the Removal of Adenoids and Large Tonsils. — 
Many children with symptoms pointing to the 
existence of adenoids are found upon exami- 
nation to be suffering from some other affec- 
tion. The conditions which have been found 
to simulate adenoids comprise the following: 

1. Diminutive choanal and nostrils. These occur frequently and in 
association with a low vault of the pharynx and other anomalies of develop- 
ment in subnormal children. These defects appear to be of rhachitic origin 
in some cases. 




Fig. 



90. — Adenoids after 
Operation. 



RETROPHARYNGEAL LYMPHADENITIS AND ABSCESS 



197 



2. Paresis of the soft palate and pharynx. This affection is sympto- 
matic of a number of conditions. 

3. Septal anomalies. The septum may be prolonged backward into 
the nasopharynx, dividing the latter into two compartments. 

4. Forward projection of the vertebral column, usually due to deformity 
of the arch of the atlas. 

5. Retropharyngeal abscess and the enlarged lymph ganglia from which 
the former originates. 

6. Undue prominence of the soft parts over the internal pterygoid plate. 

7. Ordinary neoplasms of the nasopharynx. 

RETROPHARYNGEAL LYMPHADENITIS AND ABSCESS 

The vast majority of cases in children arise from suppuration of the 
lymph nodes, and not from caries of the spine. Infection of pharyngeal 
lymph nodes takes place from the mucous lining of the nasopharynx. It 
may be tuberculous, but generally it is simply inflammatory. The writer 
has known it to develop in children whose pharynx had been repeatedly 
examined with the fingers by medical students. 

Symptoms and Diagnosis. — Young children, when brought to the phy- 
sician suffering from an incipient retropharyngeal abscess, are restless and 
refuse food. They have a nasal cry, " voix de canard," and at first no definite 
localization of the fever or its cause is possible. Gradually the throat 
symptoms increase; the breathing becomes noisy and dyspnoea is urgent, 
particularly in cases in which the abscess is low down, and swallowing 
is difficult and painful and accompanied by regurgitation. The head is 
held in a characteristic position and turned to one side. On examining the 
throat by reflected light or sunlight, we find it in a swollen condition, and 
in the majority of cases we notice a bulging of the posterior pharyngeal 
wall. Careful digital examination will tell us more definitely the extent 
and location of the soft fluctuating tumefaction. In rare instances a sudden 
attack of dyspnoea is the first symptom noticed. 

Differential Diagnosis. — A diphtheritic pseudomembrane is absent 
and there are no hoarseness and aphonia, as in croup. Adenoids and en- 
larged tonsils will give almost identical symptoms and may also be present 
as a complicating feature. The educated finger will recognize the actual 
condition with which we have to deal. 

Treatment. — A localized accessible abscess may be opened by direct 
incision through the mouth. A thin walled abscess may be punctured by 
means of a blunt dressing forceps, and the branches of the forceps may be 
spread to encourage free exit of the pus. The child's head must be lowered 
to prevent flooding of the larynx. A retropharyngeal abscess opened by 
a simple small incision is apt to close and fill again, but an opening made 
by a blunt instrument does not heal up. In operating from the mouth 
narcosis is usually not feasible. 

In the presence of marked dyspnoea and a deep seated abscess low down 
and difficult to reach, and in those cases in which the pus has spread down- 
ward toward the lateral surface of the neck, a direct incision from outside 
behind or in front of the sternocleidomastoid muscle and under antiseptic 



198 



PEDIATRICS 



precautions is indicated. In weak babies under one year opening the ab- 
scess through the mouth is to be preferred, on account of the danger 
associated with general anaesthesia. Tracheotomy is rarely called for, as 
it usually takes a week before suffocation becomes imminent. Intuba- 
tion is not applicable in such cases, as the swelling would override the end 
of the tube. 

Prognosis. — In cases of retropharyngeal abscess in children the prog- 
nosis depends upon the age of the patient and the time and manner of 
treatment. Death may occur slowly from asphyxia or suddenly, in ad- 
vanced cases, from suffocation, due to rupture of the pus sack. Pus may 
burrow in various directions or discharge through the ear. A timely 
incision will save almost all the patients. 

Nasal intubation by means of soft rubber tubes is sometimes applicable 
in cases of dyspnoea due to acute nasopharyngeal swelling in infants. 



ERUPTIVE AND OTHER FEVERS 

MEASLES ; MORBILLI 

Introductory Remarks. — An acute infectious and highly contagious dis- 
ease, the specific microorganism of which has not been isolated, character- 
ized by a prodromal stage with coryza, fever, cough, "dull eyes " or pink 
eyes, followed by a brownish red macular and papular eruption. The 
period of incubation is not definitely known, but is supposed to be from 
seven to eleven days. If sixteen days elapse after exposure without the 
disease developing, the person may be considered safe from an attack. 

The exanthem appears about the fourth day, first on the face, which 
has a mottled and swollen appearance, and spreads over the trunk and 
entire body. It is also visible on the mucous surfaces of the mouth and 
throat. The skin eruption lasts until the sixth or seventh day, and then 
gradually fades. A desquamation occasionally sets in in the form of very 
minute scales. 

Peculiarities of the Preeruptive Stage in Measles. — As a fore- 
runner of the rash, small red spots, "Koplik spots," with a minute blue white 
centre, have been described by Flindt, Reubold, Flatow, Hilton, Fagge, 
Koplik, and others as occurring on the inner surface of the cheeks in many, 
but in not all cases. Dr. M. Flindt, in the records of the Danish Sundheds 
Collegium, 1880, describes these spots as follows: "Second day of fever: A 
spotted erythema may be seen on the mucous membrane of the cheeks 
and lips. This shows quite a remarkable appearance, due to the numerous 
minute bluish white, shining, and apparently vesicular points which lie 
in the centre of small red spots and are arranged in irregular groups. One 
can feel as well as see the small vesicles projecting above their surroundings. 
Third day of fever: Similarly grouped spots with vesicles are visible on 
the buccal mucous membrane, especially on the part of it lying opposite 
to the space between the upper and lower back teeth. At this stage the 
skin eruption first makes its appearance." Dr. Koplik, of New York, de- 
scribes these spots in the Medical Record of 1898 (No. 1431), and distinctly 



MEASLES 



199 



points out that they are often present from twelve hours to five days 
before the cutaneous eruption, and that their presence may enable us to 
isolate our cases earlier than formerly and aid us in distinguishing measles 
from other skin eruptions. 

Another peculiarity of measles infection, according to the experience 
of the writer, is that the temperature curve in the preemption stage may show 
a remission to normal or subnormal at irregular periods on the febrile days 
preceding the eruption, as shown in the chart. The knowledge of these 
points is important as regards the early recognition of the disease and the 
isolation of the patient. (Trans, of the Amer. Paid. Soc, June, 1898.) 

Prognosis. — Uncomplicated cases end in recovery. In the form known 
as hsemorrhagic, or black, measles death often results from an overwhelming 



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Fig. 91. — Temperature Curve in Measles. 



toxaemia. In adults measles is usually of a severe type; in infants and 
delicate children it is often fatal. 

Differential Diagnosis. — In rubella the rash appears earlier, it is 
evenly distributed and not blotchy, and all the symptoms are mild. Scarlet 
fever has a sudden onset and no preemptive remission. The throat is 
sore and the rash is scarlet; the eyes are bright. 

Prevention. — One attack usually confers immunity. It is so highly 
contagious that it is extremely difficult to keep it out of children's hospitals 
and wards. Plastic operations should not be attempted on children who 
have not had measles and who have recently been exposed, on account of 
serious interference with the healing process in the event of their being 
attacked with measles. 



200 



PEDIATRICS 



Treatment. — We have no specific medication for measles. The patient 
is given a warm bath and an enema or laxative, and kept in bed, isolated, 
for a week. The room should be well ventilated and not heated above 
68° F. The patient should have a fever diet and cooling drinks. Very- 
high fever is managed by hydrotherapeutics (see General Therapeutics). 
The nasopharynx is to be kept moist and clean by dropping salt water 
from a spoon or pipette into each nostril four times a day. This will also 
ameliorate the throat cough. A warm bath may be given daily, and the 
eyes may be frequently washed with boric acid solution. In extreme 
restlessness a single dose of antipyrine or phenacetine may be given at 
night. When the cough is very annoying, from 5 to 10 drops of paregoric 
may be given occasionally. 

Complications and Clinical Varieties. — Incessant hacking cough; croupy 
cough; aphonia and stenosis of the larynx; active angina; follicular ton- 
sillitis; visible diphtheria and croup; nasal diphtheria early or late (often 
overlooked) ; late membranous croup ; pertussis ; bronchopneumonia and 
lobar pneumonia or tuberculosis of the lung; severe conjunctivitis; sto- 
matitis and gastroenteritis; gangrene in the mouth; gangrene elsewhere; 
otitis media. 

If there is the slightest indication of a membrane in the throat or nose, 
or progressive hoarseness with stenosis, full and repeated doses of diphtheria 
antitoxine should be given (see Diphtheria and Croup). When a nasal 
discharge persists after the measly eruption has disappeared, and particularly 
if the discharge is bloody or offensive, a culture should be made and search 
undertaken for the Klebs-Loeffler bacillus. If hoarseness and aphonia 
develop, with a nasal discharge, after measles, antitoxine is indicated at 
once, even if the throat is clean. 

The various other complications of measles are discussed under the 
various headings. In rare instances hoarseness and a mild degree of 
stridulous breathing may persist for a long time following measles. This 
complication, which may be termed a chronic laryngitis, is not improved 
or cured by medication. In such a case the child should be sent to the 
country or to the seashore, away from a dust laden atmosphere. The 
administration of potassium iodide by the mouth or rectum, gr. 11 to 5 
three times a day, is rational whenever syphilis is suspected as an under- 
lying cause of such hoarseness. 



RUBELLA; ROTHELN ; GERMAN MEASLES 

This infection is seen in two types, one resembling mild measles and the 
other resembling mild scarlatina. The rash comes out in pinkish spots 
(maculo-papules) on the first or second day. It appears first on the face 
and spreads over the whole body. It persists from three to five days, 
and may be followed by a slightly perceptible desquamation. The tem- 
perature is seldom more than 100° or 102°. In the absence of a bacterio- 
logical test it cannot, except in theory, be distinguished from mild measles. 
It is contagious, and there is swelling of the posterior cervical glands. It 
Occurs in epidemics, it is distinct from measles and scarlet fever, and it 



SCARLET FEVER 



201 



may be confounded with measles, scarlatina, influenza, and erythema 
multiforme. Complications and sequelae are seldom observed. 

The treatment is by isolation and rest in bed for a week, liquid diet, 
fresh air, and attention to the bowels. 

VARICELLA (CHICKENPOX) 

A papular eruption ushered in with slight fever and malaise and occa- 
sionally a temperature of 103°. The eruption becomes vesicular in a short 
time, and the vesicles are frequently surrounded by a narrow area, or circle, 
of hyperamiia. The vesicles may hold a clear or cloudy fluid and may 
become umbilicated. In drying up they form a crust which drops off without, 
as a rule, leaving a scar. The vesicles may appear in successive groups. 
The contagium of the disease has not as yet been isolated, and it is at times 
very difficult to discriminate between varicella and varioloid. Chickenpox 
is not rare in adults. 

The symptoms are those of a mild infection, with general malaise and 
slight fever before the . eruption. In discriminating between varioloid 
and varicella we should be guided by the following points: In varicella 
the eruption usually appears first upon the trunk, rarely on the forehead 
or face. The vesicles vary in size, break readily, and are superficial with 
a very slightly marked red areola. They develop in successive crops. 
All stages can be seen side by side. There is usually a history of exposure 
to varicella. The constitutional symptoms are mild. In variola there is a 
more sharply defined hypersemic area surrounding the variola vesicle. In 
the early stage of its eruption the forming vesicle feels like " shot " under- 
neath the skin. In smallpox the hands and feet usually show hard and 
circumscribed papules. Varicella and scarlet fever may occur together. 
In rare instances the skin becomes infected through a broken vesicle, or 
pock, and erysipelas or gangrene of a patch of tissue may result. Un- 
complicated cases of chickenpox get well. 

Treatment. — Direct quarantine in a well ventilated, sunny room, order 
soft diet, and open the bowels. The eruption in the mouth requires a 
mouth wash of chlorate of potassium (2 per cent solution). For varicella 
of the vulva we apply cold cream. 

SCARLET FEVER 

Introductory Remarks. — Scarlet fever is an infectious disease the specific 
poison of which, highly contagious and capable of reproducing itself, has 
not as yet been isolated. It probably enters the system through the naso- 
pharynx and respiratory tract, and may be conveyed in all the ways in 
which contagious disease is distributed. The main factor in the causation 
of epidemics is personal intercourse. It is believed, but not proved, that 
domestic animals may contract scarlet fever transmissible to man. Milk 
epidemics and drinking water epidemics, as reported in literature, lack 
bacteriological proof. The common mode of infection is by direct or inter- 
mediate contact with a scarlatinous patient, and by contact with the secre- 
tions, excretions, and exhalations of the body, and by means of books, toys, 



202 



PEDIATRICS 



etc., soiled by patients having scarlet fever. The period at which scarlet 
fever is most contagious and the duration of capacity for infection are not 
definitely known. The susceptibility and immunity of individuals and 
families, and the period of incubation, are inconstant; the latter varies 
from a few hours to a few weeks. No age, sex, or race is exempt. Few 
cases, however, occur in adults. Ill ventilated and filthy localities are 
favorable for the propagation of scarlet fever. Most cases occur during 
the cold season of the year, when the closing of windows prevents proper 
renewal of air in the houses. 

The severest forms are observed in children of a lymphatic diathesis 
whose nasopharynx is not normal (croupy children). On the other hand, 
scarlet fever complicated with diphtheria may run a comparatively safe 
course in children afflicted with adenoids and enlarged tonsils and generally 
of anaemic appearance. This would naturally lead to the inference that the 
contagion had various degrees of virulence, and that the blood offered 
more resistance to the infection in one case than in another. Regarding 
this important question we are still in the dark. 

The mortality may be as low as 5 per cent in some epidemics, and as 
high as from 30 to 40 per cent in others. According to the reports of the 
New York State Board of Health, scarlet fever is most prevalent in the 
first four months of the year. 

Infection ceases with the termination of desquamation and convalescence. 
The failure to establish the origin of sporadic cases is due to defective 
methods of investigation in the absence of positive knowledge as to the 
exact nature of the poison. 

Scarlet fever is very prevalent and has a large mortality and many 
and dangerous sequelse; thus the wisdom and necessity of preventive measures 
are self-evident. The poison of scarlet fever may be diluted and rendered 
innocuous by persistent ventilation and disinfection; this, together with 
isolation of the patient, limits the spread of infectious disease in a household, 
institution, or community. The fact that some contagious diseases are 
infective during the preemptive stage is no argument against the necessity 
of taking active preventive measures for the three or four weeks following, 
during which time infection still continues. At least three weeks should 
elapse from the date of exposure before freedom from danger of an attack 
is secured. 

The period op incubation is supposed to vary from one to seven days. 
A child exposed to scarlet fever contagium and remaining free for two 
weeks may be considered out of danger. The utmost care should be ex- 
ercised to keep scarlet fever out of lying-in and operating rooms. 

Mother and infant may have scarlet fever after childbirth, and in many 
instances the results of plastic operations are marred by flaps sloughing 
from scarlatinal disease following operation. 

After the discovery and isolation of the specific poison of scarlet fever, 
which is not unlikely to take place in the near future, we may also hope to 
obtain specific means to immunize and cure. Under all circumstances it 
is the duty of the general practitioner to inform himself as regards the best 
methods of prevention and disinfection, and to urge their adoption in every 
case coming under his notice and care. These methods of prevention are 



SCARLET FEVER 



203 



applicable to all infectious diseases and are discussed in a special chapter 
on Infective Fevers. 

Onset and Symptoms. — The disease begins abruptly as a rule with 
vomiting and thirst, rarely with a chill; young children may have convul- 
sions. The fever rises to 104° or 105°, the pulse is rapid (120-150), the 
respiration is increased in frequency, and the child complains of sore throat. 
The scarlet rash appears on the second day, on the neck and chest 
first, and may spread over the entire body within the next twenty-four 
hours. The rash is punctate or finely papular, diffuse or in patches, and 
slowly disappears after persisting from two to five days. The throat looks 
red and swollen, and the tonsils may be covered with a punctate exudate. 
Pseudomembranes and diphtheritic patches are often seen on the tonsils 
and pharynx. From the gross appearance of these patches one is unable 
to say whether they are Klebs-Loeffler or streptococci patches. As a rule 
they are of a mixed nature. Minute macules of a dark red color are gener- 
ally seen on the hard or soft palate. The lymphatic glands of the neck 
are swollen. The tongue is at first covered with a fur, and after a few days 
exfoliates and becomes red ("strawberry tongue "). Headache, general 
restlessness, insomnia, and delirium are present in severe cases. The urine 
is scanty and may contain albumin and hyaline casts. In favorable cases 
the temperature becomes normal on the seventh or eighth day, and desqua- 
mation sets in, lasting three weeks on an average and occasionally from 
six to eight weeks. 

Differential Diagnosis. — In the absence of a bacteriological test, it 
may be difficult and often impossible (except by those who can see the 
grass grow) to distinguish a scarlet fever rash from a scarlatiniform rash, 
such as we occasionally observe after the administration of certain drugs: 
Belladonna, quinine, antipyrine, iodoform, balsam of copaiba, etc., and also 
in cases of intestinal indigestion. Slight desquamation may even take place 
in a skin which has been the seat of a scarlatiniform rash, and desquamation 
following measles is nothing rare. 

The measles rash is of a brown red color, and presents itself in large 
irregular spots. The patient has coryza, cough, sneezing, and dull eyes. 
In German measles the throat symptoms are absent- 
Diphtheria with a scarlatiniform eruption cannot be distinguished 
clinically from a scarlet fever infection with diphtheritic sore throat; and 
as regards the drug and indigestion rashes, each case must be judged upon 
its merits. With a clear throat and normal temperature, it would seem 
unnecessary to quarantine a patient who happens to have a suspicious 
rash. 

Prognosis is uncertain. The mortality varies from 5 to 30 per cent. 
We have no means of gauging the power of resistance of the individual 
as regards sepsis, and, even when the acute stage is safely passed, subsequent 
complications may endanger and destroy life. Severe throat symptoms, 
early delirium, uncontrollable vomiting, high temperature, and high pulse 
are unfavorable symptoms. This is a brief pen picture of a moderately 
severe case of scarlet fever terminating favorably in due time. Apart from 
this form, we observe every variety as regards severity, complications, and 
sequela?. 



204 



PEDIATRICS 



The mild form may present itself with the rash, a red throat, and a 
temperature of from 100° to 101°, or the rash without throat symptoms 
and without fever. In this form the pulse is from 100 to 120. 

The severe form may present an initial diphtheria which spreads over 
the nasopharynx, with extensive pseudomembranous inflammation and 
much glandular swelling, invasion of the middle ear, and evidence of scar- 
latina on the second day. 

Malignant Form. — Initial throat symptoms with a yellowish greenish de- 
posit on the tonsils and throat, a scarlet rash on the second day coming 
out sparingly, a pultaceous condition of the throat, vomiting incessant, 
temperature high, pulse 150 to 180, active delirium, and death on the 
third, fourth, or fifth day. 

The ordinary onset with diphtheritic complications at the end of the first 
or second week. Heart, lungs, and kidneys free. 

Hemorrhagic Form. — A black eruption, petechial or in large ecchymoses, 
with hematuria and other evidence of intense sepsis usually fatal from 
the second to the third day. Some patients recover. 

Fatal Septic Form. — Onset sudden and intense, temperature 106° to 
107°, delirium, vomiting, convulsions, coma, and death before the rash 
has had time to develop. 

Scarlatina and measles may coexist in the same person. Wounds 
predispose to the development of scarlatina (surgical scarlet fever). 

Treatment. — In very mild cases the children are to be put to bed on fever 
diet, and they require no other treatment. As soon as a child is known to 
be ill (with vomiting, fever, and sore throat), it should receive a warm bath, 
of 100°, and an enema, and be put to bed and isolated in a room the tem- 
perature of which is not over 65° to 68°. Should an inspection of the throat 
reveal a patch of pseudomembrane or a puslike exudate, 2,000 diphtheria 
antitoxine units should be injected at once and a swab culture taken. 
If diphtheria bacilli are reported found, the antitoxine injection should be 
repeated on the following day, and as often thereafter as may be necessary 
to check a complicating diphtheria. Diphtheria sepsis is not so readily 
checked by antitoxine in scarlet fever cases as in the uncomplicated variety, 
but in the experience of the author it does no harm and is the only rational 
specific treatment which we possess. The antitoxine may be administered 
daily or every other day, according to the indications, in precisely the same 
manner as in primary diphtheria without scarlatina. 

So long as there is much vomiting, ice to suck and cold and hot drinks 
are indicated. A fever diet is indicated. A strict milk diet is not of special 
import, but as milk is a perfect food in itself, it may be given to a patient 
exclusively if he will take it and tolerate it. Water should be given in 
considerable quantities to assist in elimination. When the vomiting has 
stopped, a good dose of calomel should be given, followed by a saline, to 
clear the bowels. 

A complicating diphtheria requires the nasopharyngeal toilet in addition 
to the antitoxine; and a cold compress may be put around the neck. Gar- 
gling with antiseptic solutions used in nasal irrigation is indicated for 
older children. 

Stimulation is indicated at any stage of the disease if the pulse is weak. 



SEVERE SYMPTOMS IN SCARLET FEVER 



205 



The treatment of scarlet fever by means of scarlet streptococcus serum is in 
the experimental stage. 

For nervous symptoms use the ice cap, baths, one or two doses of phena- 
cetine, or citrophen, gr. ij to v. 

Otitis media with perforation of the drumhead is a frequent complica- 
tion. Occasionally complete deafness persists for a time, but eventually 
the hearing is reestablished in most cases. The indications for perforating 
the drumhead are discussed elsewhere (see Otic Memoranda). A discharg- 
ing ear is best managed by gentle irrigations with 2 per cent boric acid 
solution every three hours. To allay pain, a lukewarm boric acid solution 
holding 2 grains of cocaine to the ounce may be dropped into the ear 
from a spoon. Inflation of the ear by means of the Politzer bag or catheter 
should not be practised, on account of the danger of forcing septic material 
from the nasopharynx into the middle ear. 

Croup and stenosis of the larynx are managed according to the rules 
laid down in the chapter on Croup. 

Bronchitis may call for the administration of an expectorant, such as 
the aromatic spirit of ammonia. 

Painful and swollen joints are no unusual manifestations in scarlet 
fever and call for the administration of sodium salicylate and frequent cold 
compresses with the limb in a comfortable position. Torticollis following 
scarlet fever is occasionally observed. Swollen lymph nodes can be felt 
underneath the muscles of the neck in such cases. Mild massage is the 
proper treatment. If vomiting persists, a drop of tincture of iodine in a 
teaspoonful of sweetened water or peppermint water may be given every 
two or three hours. 

Treatment for Severe Symptoms, Complications, and Sequel.e. — 
Hyperpyrexia is best treated by warm baths and a single dose of an anti- 
pyretic, according to the rule laid down in the article on Pneumonia. 

In severe sepsis (rapid heart, delirium, high temperature) the patient 
may be kept in the warm bath for an hour at a time. The bath tub must 
be covered with a blanket in such a manner that only the head of the patient 
is exposed, and the bath room must be warm (75° to 80°). Stimulants 
may be given to the patient when he is in the water. After the vomiting 
is checked and the tongue remains coated, it is wise to give a few drops 
of dilute hydrochloric acid in sugar water three times a day, to aid digestion. 
Regarding the management of meningitis as a complication of scarlatina, 
the reader is referred to the article on Meningitis. 

Local Treatment of the Nose and Throat. — In the mild as well as 
in the severe anginas the nasopharyngeal toilet is indicated. Swabbing or 
cauterization is not indicated. In the diphtheritic variety, in which anti- 
toxine is indicated, as already mentioned, it often happens that the swelling 
in the nasopharynx is so intense that swallowing is difficult, and a foul 
discharge and odor are noticeable from the nostrils. Such cases should have 
regular energetic irrigation of the nostrils in accordance with the rule in 
the article on Nasopharyngeal Diphtheria. 

When external sloughing is observed, a moist dressing of camphor 
water or balsam of Peru is probably the best. An extension of the diph- 
theritic process into the larynx, with stenosis, requires intubation. 



206 



PEDIATRICS 



Itching of the skin may be allayed by sponging with 1 per cent carbolic 
acid water, or soda in water, or the free use of starch powder. 

Prolonged fever lasting for several weeks which cannot be localized is 
occasionally observed in otherwise uncomplicated scarlatina. It may be 
due to infection and swelling of deep seated glands and to other causes, 
and requires no special medication. Opening the bowels, warm baths, the 
breathing of good, cool air, and good feeding, with hydrochloric acid to 
aid digestion, constitute the proper treatment in such cases. 

Nephritis and dropsy in the wake of scarlatina are nothing unusual. 
The urine may contain blood or albumin and all sorts of casts. In this 
condition children may subsist on milk if they will take it. Warm tub 
baths and hot air baths in bed, under cover, may be employed, and an 
occasional dose of calomel or some other laxative is always in order. In 
"urgent cases we may give an infusion of digitalis ( 5ss to § iij) , a teaspoonful 
every three hours. This increases diuresis by increasing the blood pres- 
sure. Or "we can give one twelfth of a grain of pilocarpine once or twice 
a day as a diaphoretic and eliminant. In complete suppression of the 
urine life has been saved by cutting down upon the kidneys and split- 
ting the capsule of the congested and inflamed organ, thereby relieving 
its tension. 

Exfoliating dermatitis is occasionally observed as a complication of 
scarlatina. The entire skin is eczematous and moist, and a rise of tempera- 
ture accompanies the inflammation of the cutis. Desquamation then sets 
in and terminates in uninterrupted convalescence; or a renewed attack of 
dermatitis ensues, and death may finally result from exhaustion. Here, 
as in most other complications, the treatment is eliminative. The eczema- 
tous skin may be covered with cloths moistened with a weak lead lotion or 
soaked in Carron oil (sweet oil and lime water), or with ichthyol vaseline 
(1 per cent). The ordinary non-inflammatory desquamation is managed 
by a daily bath and vaseline inunctions. 



GLANDULAR FEVER 

Pfeiffer, in 1889, drew attention to the following clinical symptoms 
complex occurring in children of all ages: Sudden onset; high fever (104°); 
pain in the joints; restlessness; vomiting; slight coryza and cough; congested 
fauces; pain in the neck and on swallowing; constipation; large and painful 
lymph nodes in the whole circumference of neck, but particularly at the 
nape of the neck, generally on both sides. In the mild form the fever 
subsides on the second day and the glands gradually subside. The severe 
form may last from eight to ten days. Suppuration is rare. Nephritis 
is an occasional complication. 

Glandular fever appears to be an acute infectious lymphadenitis of 
obscure origin. The portal of entrance is probably the upper respiratory 
tract. 

The prognosis is favorable. 

The treatment is by rest in bed, a laxative daily enema, a daily 
warm bath, and fever diet. The nasopharyngeal toilet should be used. 



MALARIAL AND TYPHOID FEVERS IN CHILDREN 



207 



In protracted cases a few doses of sodium salicylate or quinine saccharinate 
may be given. 

MALARIA IN CHILDREN 

Malarial fever as an infectious disease is fully discussed in the chapter 
on Infectious Fevers. In older children this disease runs about the same 
course as in adults. In younger children we observe, first, the acute form, 
in which the onset is occasionally ushered in with chills or convulsions with 
coma (the cerebral type) ; second, the chronic form, in which the children 
are anaemic and frequently suffer from stomatitis with swollen lymph nodes 
and an enlarged spleen; and, third, the masked, or irregular, type. When 
an intermittency of fever is observed, it is usually of the quotidian or tertian 
type. Chills do not set in so abruptly as in adults, and the spleen is not 
regularly enlarged. 

Clinical Types of Malaria in Children. — 1. The cerebral type, of acute 
and subacute onset with high temperature, convulsions, and coma. 

2. Malarial infection with bronchopneumonia. 

3. Malarial infection with acute enteritis. 

4. Malarial infection with torticollis. 

5. Malarial infection with acute and chronic nephritis. 

6. Malarial infection with a gradually developing endocarditis. 

7. Masked malaria (malaise, neuralgia, stomatitis with enlarged lymph 
nodes). 

The masked types particularly are of daily occurrence in the practice 
of medicine in malarious districts. 

Diagnosis. — The diagnosis is established by means of a blood examina- 
tion (see Laboratory Diagnosis) and also by means of the therapeutic test, 
i. e., the administration of quinine sulphate or "sweet quinine " in 3 to 5 
gr. doses. 

Treatment. — Quinine is a specific for malarial fever. Children take it 
in 2, 3, or 5 grain doses twice or three times a day. In order to disguise 
the bitter taste to some extent, it is best given in suspension in compound 
elixir of taraxacum or in honey. Fluid extract of licorice or elixir of yerba 
santa will also hide the bitter taste of quinine salts. After the medicine is 
swallowed, older children may taken a lemon candy into the mouth to still 
further hide the taste of the specific drug. 

Sweet quinine (saccharinate of quinine) is now obtainable. It has about 
the same strength and therapeutic value as the bitter sulphate. It may 
be given in compressed tablets. 

Euquinin is a quinine preparation adapted for children. It is given in 
the same dose as the sulphate of quinine. 

TYPHOID FEVER IN CHILDREN 
Typhoid fever is comparatively rare in infants, but it is more frequently 
met with in older children; it is usually of a mild character, although cases 
of a severe type do occur. The diagnostic features and treatment are similar 
to those in adults. (See Typhoid Fever.) 



208 



PEDIATRICS 



VULVOVAGINITIS 

We observe three varieties of vaginal discharge in children: 

A simple leucorrhoea is not an uncommon occurrence in anaemic or ill 
cared for little girls, and usually subsides as soon as local cleanliness and 
proper hygienic and tonic management are inaugurated. 

The simple purulent vulvovaginitis, as observed in little girls, may be 
due to mechanical irritation, masturbation, worms, or uncleanliness, or may 
follow exanthematous diseases, and sometimes it arises without apparent 
cause. It shows no tendency to spread into the bladder or pelvis, but it 
is communicable and may give rise to inguinal adenitis, mild purulent oph- 
thalmia, or a pustular eczema on account of scratching with unclean fingers. 
The distinction of the simple purulent vulvovaginitis from the specific, 
or gonorrhceal, variety is accomplished with the aid of the microscope. 

Treatment. — The parts must be carefully cleaned by wiping the dis- 
charge away with moistened absorbent cotton and douching with a sal 
soda solution and afterward with sulphocarbolate of zinc, 5 per cent solution, 
or 5 per cent alum water. When the parts appear much irritated, stearate 
of zinc should be dusted between the labia. Worms, if present in the 
intestines, should be discharged. 

Specific, or Gonorrhceal, Vulvovaginitis. — -This variety is due to the 
presence of a diplococcus (see Laboratory Work), is highly contagious, and 
may give rise to severe gonorrhceal ophthalmia, suppurative inguinal adeni- 
tis (bubo), cystitis, pyosalpinx, pericarditis, pelvic or general peritonitis, 
and gonorrhceal arthritis with severe heart complications. In recent cases 
the infected vaginal mucous membrane is swollen, bleeds easily, is eroded 
in places, and is covered with a foul smelling purulent discharge. 

Regarding the mode of infection, it may be stated that in children of 
both sexes the usual mode of infection is responsible for the disease in some 
few cases. The majority of cases may be traced to the child's sleeping in the 
same bed or playing with and touching a person suffering from gonorrhoea. 
In some instances soiled linen and water closet seats and infected catheters 
have been held responsible. Infection will often lurk in the vulvovaginal 
gland and its duct, in the urethral follicles, and in the deeper recesses of 
the vagina, although the more accessible, visible parts are in a healthy 
condition on ordinary examination. Thus, we have latent, or unsuspected, 
vulvovaginitis , which may start up again at any subsequent time and give the 
impression of a new acute attack. Therefore the presence of gonorrhceal 
discharge in a little girl, without marks of injury to the genitalia, does not 
prove a recent acute infection or that an assault has been attempted. 

Treatment. — The parts must be cleansed frequently, as already de- 
scribed, and the vagina thoroughly swabbed with a 2 per cent protargol 
solution on a cotton carrier twice a day or a 2 per cent nitrate of silver 
solution. An atomizer may also be used to advantage, and over night a 
protargol suppository may be inserted into the vagina, gr. j to grs. v protargol 
of cacao butter. If the application of the disinfecting agent produces 
severe smarting, it may be applied in less strength. 

The treatment after the first week should be less active, but should 
continue for from six to ten weeks. Even after the gonococcus has dis- 



FAMILIAR FORMS OF NERVOUS DERANGEMENTS 



209 



appeared from the discharge relapses are frequent. During the time of 
treatment the child must wear a pad. Cases occurring in the wards of a 
children's hospital must be strictly isolated. 

Vaginal douching with antiseptic solutions are occasionally followed 
by severe local pains in the pelvis and bladder, with a fever temperature. 
Careful douching with the fountain syringe but slightly elevated and the 
child in Sims's position is effective and devoid of danger. With proper 
treatment and when precautions as to complications are taken, the prognosis 
is good. A complete and rapid cure should not be promised. In young 
girls, in lieu of the fountain syringe for purposes of irrigation, a small soft 
catheter attached to a piston syringe should be employed. As an irrigation 
fluid permanganate of potassium, 1 to 4,000, may be used. At first two 
injections should be made daily; subsequently one a day; and finally two 
or three a week. After irrigation the parts should be dusted with stearate 
of zinc and a gauze pad applied. 

The early detection of vaginal discharges of gonorrhceal origin in young 
children in day nurseries, kindergartens, and primary classes in public 
schools is of the utmost importance in preventing the spread of this malady 
and its complications, such as contagious ophthalmia, etc. To illustrate 
the dangers of gonorrhceal infection in children in public schools, the fol- 
lowing authentic instance is cited: In a public institution in New York 
City harboring 850 children, 130 cases of so called leucorrhcea developed in 
two months, which proved to be gonorrhceal in nature. A large number 
of these children attended public schools. After numerous complaints by 
parents of children subsequently infected had been made, the matter was 
carefully investigated and proper isolation was effected. 

MASTURBATION IN INFANTS (THIGH FRICTION) 

An early recognition of this habit is important, inasmuch as the practice 
can easily be stopped in the beginning, whereas if it is neglected until the 
children are older, the habit is apt to become firmly established. Thigh 
friction can be prevented by any mechanical device which will keep the 
legs apart; but such a contrivance would be of no value in cases in which 
the child used its hand. For such cases a breech corset and leg separator 
combined would be necessary. Local irritation and irritation from highly 
acid urine should be recognized and treated, and general tonic management, 
including cold sponging, is indicated in cases of this nature. Masturbation 
in older children is overcome by tactful management by the parents 
and physician. Preputial adhesions are the most fruitful sources of local 
irritation. 

FAMILIAR FORMS OF NERVOUS DERANGEMENTS PECULIAR 

TO EARLY LIFE 

TICS; HABIT SPASMS; PAROXYSMAL RUNNING IN CHILDREN 

Facial tics, facial nerve, spinal accessory, and hypoglossus spasms 
(trigeminal tics) are due to some central or peripheral irritation, as are 
also the bladder tics and heart twitching. 
15 



210 



PEDIATRICS 



Habit Spasms. — Simple tics are under the control of the will to a certain 

extent. The muscles of the face, neck, shoulder girdle, arms, and legs are 
involved. Usually some source of irritation, such as adenoids or eye strain, 
can be elicited. They are annoying and very resistant to treatment, and 
may be associated with explosive utterances and cries and imperative ideas, 
or show as complex coordinated tics, such as head nodding and head banging. 

Psychic tics, or imperative ideas, impelling the victim to touch a certain 
object or count a certain number, etc., are not serious. 

Paroxysmal running is a morbid phenomenon of the explosive sort, 
suggesting cerebral excitation. The running may be in a straight line, in 
large circles, or irregular. There are two types: The first is associated 
with such diseases as epilepsy and mental derangement; the second is 
associated with chorea or hysteria. An underlying neurotic constitution 
is at the bottom of all tics, and in many instances some local irritation can 
be determined. Children of alcoholic and syphilitic parentage are prone 
to show tics. Anaemia and malnutrition intensify the liability to tics. 

Treatment. — Neurotic children should not be overlooked at school, 
and should have cold douches up and down the spine, gymnastics, fresh air, 
proper food, and no intercourse with neurotic or violent individuals. In 
local tics the source of irritation, eye strain, phimosis, or adenoids must 
be remedied if possible. Local vibration and vibration along the spine are 
indicated. 

HEAD NODDING AND NYSTAGMUS IN RHACHITIC CHILDREN 

Under the titles spasmus nutans, nictitatio spastica, etc., writers have 
reported cases of clonic spasms of a group of muscles innervated by the ac- 
cessory nerve, notably the sternocleido mastoid, trapezius, and recti capitis 
muscles. This muscular unrest may be unilateral or bilateral, and ceases 
during sleep. Nothing is known as to the aetiology of this condition. In 
severe cases of long standing the prognosis is unfavorable, and the treat- 
ment is limited to the removal of any form of reflex irritation which may 
be present or is supposed to exist, plus hygienic management and the 
medication recommended for rhachitic conditions. Two cases which came 
under the author's notice presented features not hitherto described (Trans, 
of the Amer. Pcediatric Soc, 1889). 

The first case referred to was that of a child eleven months old, in which 
the choreic movements were noticed by the mother on the day following 
an injury to the head by falling from a high chair. The muscles supporting 
the head were in such a state of unrest as to seriously interfere with the 
comfort of the child. The child soon became peevish, refused to take food, 
and became emaciated in appearance. A careful examination showed a 
marked rhachitic development and nystagmus of the horizontal type. 
The eyes were examined by competent ophthalmologists, Dr. Koller, Dr. 
Schapringer, and Dr. E. Fridenberg, and, excepting nystagmus, nothing 
abnormal was detected. It was furthermore noticed that if the child's 
attention was engaged by a shining object held at some distance above 
the level of the eye, the nystagmus and choreic movements would cease 
during such fixation. It was also apparent that the movements of the head 



TETANY IN INFANCY (PSEUDOTETANUS) 



211 



were not the consequence of muscular weakness, but, on the contrary, it 
seemed as though they were due to a distinct effort on the part of the child 
for the purpose of visual fixation, made difficult by the existing nystagmus. 

Treatment. — The application of an eye bandage suggested itself, and as 
soon as this was in such a position as to exclude every ray of light the choreic 
movements ceased completely; if, however, the bandage was so applied as 
to admit but very little light, the head movements persisted. This phenom- 
enon was observed by a number of my colleagues, and could be repro- 
duced at any time. Under such circumstances a permanent eye bandage 
suggested itself as a therapeutic procedure. The bandage was properly 
applied, and removed but once a week for cleansing purposes. The child 
was carried to the riverside daily, and was treated with salt baths and 
massage. The diet was regulated and phosphorus given internally. This 
treatment was faithfully carried out by the mother, and at the end of three 
months the nystagmus and choreiform movements had ceased, and the child 
was plump and healthy in appearance. 

In a second child the symptoms manifested themselves after an attack 
of measles. At the time of its presentation there were moderate con- 
junctivitis, the nystagmus of the vertical type, and the movement of the 
head. The treatment and ultimate good results were the same as in the 
first case. 

It appears from these observations that the localized tonic muscular 
spasms were either compensatory to the movements of the eyeball or reflex 
from irritation occasioned by the light to those structures which are con- 
cerned in carrying the impression. In view of the fact that the choreic 
movements ceased as soon as all light was excluded from the children's 
eyes, I am unable to formulate a more satisfactory explanation of the 
phenomena observed than the one I have expressed. 

NIGHT AND DAY TERRORS (PAVOR NOCTURNUS ET DIURNUS) 

Mild and severe cases of nightmare may be due to gastrointestinal or 
respiratory disturbance — nasal obstruction. In some instances of circu- 
latory disturbances consciousness is lost and the little patient appears to 
have no knowledge of the attack on awakening. In most instances there 
is an underlying neuropathic anaemic constitution. In the management 
of such cases it should be remembered that ill ventilated, dark rooms, late 
meals, exciting games, and story telling before bedtime favor the attacks. 
When night terrors are of central origin, they do not yield to ordinary 
hygienic management, and must be regarded with gravity. 

TETANY IN INFANCY (PSEUDOTETANUS) 

In the present state of our knowledge tetany may be defined as symp- 
tomatic intermittent paroxysmal muscular rigidity occasionally observed 
(1) in rhachitic infants and children, (2) in cases of intestinal putrefaction 
and autointoxication, and (3) as an associated feature or sequel of acute 
infectious fevers. In a study of seventy-one cases reported by Dr. R. A. 
Peters {Roussky Vratch, September 14, 1902), the following symptoms 



212 



PEDIATRICS 



were noted: 1. Contraction of the hands and of the feet. 2. Chvostek's 
symptom: Percussion with a hammer over the branches of the facial nerves 
produces a contraction of the facial muscles. 3. Erb's symptom: Increased 
electro irritability in the peripheral nerves. 4. Trousseau's symptom: 
Pressure upon the tendon of the biceps produces contractions in the muscles 
of the upper extremity that are quiet at the time of testing, or the con- 
tractions are increased in those muscles that are in activity at the time. 
5. A sign which the author calls "jumping jack " symptom. It consists 
of motions of the lower extremities resembling those that result from the 
pulling of a string of a paper "jumping jack " when the galvanic current 
is applied to the portions of the spine that correspond to the lumbar and 
cervical enlargements, the anode being placed on the chest, the cathode on 
the spine. The strength of the current v/as from three to four milliamperes. 
Erb's and Chvostek's symptoms were not found so constantly as the other 
signs, and were not pathognomonic. 

Prognosis. — With proper management the majority of the patients re- 
cover. 

Treatment. — Warm baths, enteroclysis, warm peppermint tea as a bev- 
erage, and proper food, together with mild massage, should be the thera- 
peutic measures. In severe cases bromide of potassium, chloral hydrate, 
chloroform inhalations, and morphine subcutaneously, gr. -^V to also 
subcutaneous injections of \ per cent carbolic acid water, 30 drops three 
times daily, may be used. 

LARYNGISMUS STRIDULUS (LARYNGOSPASM) 

Laryngismus stridulus is a laryngo respiratory spasm (neurosis) occurring 
in rhachitic children. It is characterized by a sudden holding of the breath 
with inspiratory stridulous breathing, and is common in children from one 
to two years of age. In severe attacks the patient becomes cyanotic and 
occasionally goes into convulsions. The attacks come on at odd times 
during the day and can often be provoked by passing the finger down into 
the throat. There is no fever, coryza, cough, or catarrh of any kind asso- 
ciated with this condition, except when the patient is afflicted with adenoids 
or large tonsils, in which case catarrhal symptoms are often observed. 
Enlargement of the thymus has been suggested as playing an a;tiological 
role in laryngospasm. Very little experience will enable us to distinguish 
this form of laryngismus from stridulous breathing in catarrhal and mem- 
branous croup, spells of whooping cough, and hard breathing spells. 

Treatment. — The attack can be cut short by dashing cold water over 
the abdomen. The rhachitic condition requires proper food, cold sponge 
baths, massage, change of air, and 10 drops of Thompson's solution of 
phosphorus three times a day. Bromides, chloral, and musk may be tried. 
Adenoids must be removed and the nasopharynx kept free by dropping 
salt water into each nostril three times a day or by using the albolene spray. 
In very severe cases the writer has employed vibration and tubed the 
larynx for hours or days, and apparently with good results. A fatal issue 
in laryngismus is a rare occurrence and comes unexpectedly. 



ENURESIS; BED WETTING ; INCONTINENCE 



213 



ENURESIS; BED WETTING; INCONTINENCE 

Enuresis, like convulsions, is a symptom. This annoying condition in 
children is too well known to require specification. It may be designated 
as a habit spasm of the bladder and may be nocturnal or diurnal. Leaving 
aside the cases of organic disease of the brain and cord (idiocy) and of mal- 
formations of the urethra and bladder, we may safely assume that enuresis 
in childhood must be classed as a neurosis to the extent that in individuals 
some form of reflex irritation produces the involuntary discharge of urine 
from the bladder. The conditions of malnutrition and anosmia frequently 
found associated with enuresis may and may not intensify the reflex irrita- 
bility of an individual. It is well known that in extreme forms of mal- 
nutrition and marasmus there is a well marked obtuseness of the nervous 
system. 

There are a great many varieties of enuresis. The following list embraces 
the ordinary conditions found in children in cases of enuresis. Malforma- 
tions of the urethra and bladder and organic disease of the brain and cord 
(idiocy) are not included in the list. 

Clinical Varieties of Enuresis. — Bed wetting with Digestive disturb- 
ances; large evening meal; a full bladder at night from too much water 
taken before bedtime; an abnormal condition of the urine, crystals in 
the urine; constipation; foreign bodies in the bladder, rectum, or urethra; 
a small meatus; phimosis, an adherent prepuce or clitoris, and elon- 
gated prepuce, a short frenulum; erosions and inflammations of the pre- 
puce, glans, vulva, or urethra; warts of' the glans, prepuce, or vulva; 
urethral caruncle; polyps, fissures of the rectum; worms in the rectum; 
masturbation, thigh friction; hernia, hydrocele; undescended testicle; ade- 
noid vegetations, mouth breathing; cystitis (bacteriuria) ; bed wetting in 
diabetes, rhachitis; anaemia. 

Prognosis. — Enuresis may last only a short time or continue on and 
off up to puberty. 

Treatment. — There is no routine treatment for enuresis and it is a 
fallacy to look around for a drug which will cure bed wetting. 

1. The main point is to combat the neuropathic constitution and mal- 
nutrition by cold sponge baths, proper feeding, general massage, and exer- 
cise in the fresh air. 

2. To examine the blood for anaemia and, if it is present, give iron and 
arsenic, and order fresh air and a daily flushing of the colon with warm saline 
solution. 

3. To look for and remove if possible local irritation as pointed out in 
the list of Clinical Varieties. 

4. If no local disturbance is detected, it is admissible to pass a clean 
sound and stretch the urethra, which is sometimes the seat of invisible 
erosions, stricture, or spasm. 

5. Bromide of potassium and belladonna may be given after al 1 else has 
failed to relieve the excessive irritability of the nerve centres, also chloral 
hydrate. 

6. Some relation between mouth breathing and bed wetting exists. 
Large tonsils and adenoids should be removed. 



214 



PEDIATRICS 



7. Elevating the foot of the bed at night sometimes overcomes enuresis 
by taking away irritation from the neck of the bladder. Hot sitz baths 
may be given before bedtime, and vibration along the spine and over the 
bladder may be applied every other day. 

CONVULSIONS IN CHILDREN 

Convulsions are symptomatic of some disturbance, but may be treated 
from the clinical standpoint as a separate affection. In children clonic 
convulsions are always accompanied by loss of consciousness; in adults 
convulsions may be simulated. Older children of neurotic environment 
and constitution may have tonic contractures without true loss of con- 
sciousness. We speak of tonic and clonic, general and localized, con- 
vulsions. Convulsions are common in rhachitic, neurotic, tuberculous, 
and syphilitic children. On the other hand, long continued profound 
malnutrition shows an obtuseness of the nervous system. Congenital 
contractures point to convulsions in utero. 

Motor discharges have their origin in the nerve cells, in the cortex, at 
the base of the brain, in the pontobulbar region and Rolandic cortical area, 
in the ganglion cells of the brain, or in reflex centres in the pons and medulla. 
An autopsy generally shows no changes except hypersemia, and the real 
changes are probably in the cells. Irritation of the motor centres may 
be direct, as in: Injuries at birth; hemorrhage; tumors; abscess; thrombosis; 
embolism; encephalitis; meningitis; sunstroke, etc. ; or irritation of the motor 
centres may come indirectly through the circulation, as in: Anaemia of the 
brain; hypersemia or venous congestion, as in heart disease, asphyxia, 
laryngismus, and pertussis; uraemia; poisons, vegetable, mineral, animal; 
toxines, infectious fevers; autointoxication from poisons formed in the 
intestines, urine, or blood (paraxanthin, acetone, etc.). 

Irritation of the motor centres may come as a simple reflex irritation, 
as from a foreign body in the nose, ear, pharynx, etc.; earache; gastro- 
intestinal irritation, colic; fright, anger, burns, wounds; retention of urine; 
renal and intestinal colic, etc. 

Convulsions in infectious fevers have a twofold significance. At the 
onset they denote overwhelming toxaemia, but do not necessarily involve 
a grave prognosis. When convulsions set in at the termination of a severe 
illness, it means some complication or circulatory failure, with inanition of 
the brain. During the convulsive attack the temperature may be normal 
or elevated. A convulsive seizure may be followed by coma, semicoma, 
rigidity, or paralysis, and occasionally death. 

Prognosis. — The prognosis is governed by a knowledge of the exciting 
cause. 

Treatment. — In the majority of cases convulsions in children are due 
to some gastrointestinal disturbance or to the onset of an acute infectious 
disease. The momentary treatment is entirely symptomatic. In many 
instances such prodromal conditions as twitching with restlessness and high 
temperature will warrant the administration of a bath and an enema. A 
child in a paroxysm should receive an enema at once, and be put into a 
bath 100° F. After removing the patient from the bath, an ice cap is 



CHOREA (ST. VITUS'S DANCE) 



215 



applied to the head and the patient put to bed and kept quiet. Should 
the convulsions return, the bath and enema are repeated, and chloral 
hydrate with potassium bromide (each,gr. 1 to 3) may be given by the mouth 
if the patient is conscious, or by the rectum if he is comatose. If a very 
high temperature is present, hydrotherapeutic measures for reducing tem- 
perature are indicated, or a single dose of antipyrine in water may be 
given per rectum. 

In obstinate and prolonged convulsive seizures the inhalation of chloro- 
form and the hypodermic administration of morphine (gr. j% to -js) 
are justified. If, on the other hand, the convulsions are caused by heart 
failure, camphor, strychnine, whiskey, and digitalis may be given sub- 
cutaneously in connection with enteroclysis. After the child's recovery 
from an attack the physician will direct his attention to any underlying 
or predisposing cause. In obscure cases it may be advisable to tap the 
spinal canal for diagnostic purposes. 

CHOREA (ST. VITUS'S DANCE) 

Chorea belongs to the group of psychomotor neuroses of unknown ori- 
gin, and occurs most frequently between the ages of five and fifteen. It 
is a disease characterized by irregular and involuntary muscular movements 
without loss of consciousness, affecting the muscles of volition, frequently 
associated with systolic heart murmurs, and having some obscure connec- 
tion with endocarditis and rheumatism. As the origin and pathology of 
chorea are still a terra incognita at the present time, its aetiology will not be 
discussed here beyond stating that overpressure at school and fright are 
important factors in its production, and that neurotic, anaemic, and ill 
nourished children are most liable to be afflicted. 

Clinical varieties of chorea are symptomatic chorea, caused by material 
lesions in the brain ; reflex chorea, due to reflex irritation, and idiopathic 
chorea, due to infectious and toxic influences, e. g., rheumatism. The last 
variety is the most frequent and important, and may be looked upon as an 
infectious disease or intoxication by the products of pathogenic bacteria. 

Symptoms and Course. — Chorea may be general or partial. Its course 
may be acute, subacute, or chronic. It rarely affects children under five 
years of age. The attack comes on gradually, as a rule. The child appears 
nervous and depressed, drops things held in the hand, or stumbles and falls 
or makes grimaces. Such manifestations may be one sided (hemichorea). 
The child is irritable and emotional and has difficulty in speaking. There 
is tongue tremor with inability to hold the hand out straight and motionless. 
Systolic heart murmurs are frequently heard. 

In the so called posthemiplegic " chorea," the muscles are rigid and 
contracted and the reflexes are increased. 

Prognosis. — Complete recovery is the rule. Acute chorea plus endo- 
carditis may terminate fatally. The prognosis in cases complicated by 
a cardiac murmur should be guarded. Relapses of the choreic condition 
are not infrequent. 

Management and Treatment. — A child affected with chorea should be 
put to bed and have no visitors or excitement, but be in charge of a 



216 PEDIATRICS 

competent person to entertain and nurse him. A daily bath and daily 
soap suds enema are to be given. Should the child not get sufficient sleep, 
a dose of chloral and bromide must be administered at night. A light 
and nutritious diet must be arranged. Palpitation of the heart with some 
fever may indicate the administration of 



Py Sod. salicyl., 5j; 

Potass, iodid., 5ss. ; 

Tinct. aconit. rad., gtt. xvi; 

Aquae et syrup, ad., 



M. S.: A teaspoonful every two hours. 

Fowler's solution of arsenic, gtt. 2 to 5, in combination with 5 grains 
of bromide of potassium, may be administered in water three times a day. 
With a view to combating endocarditis, which is a frequent complication 
of chorea, an ice bag may also be placed over the chest. 

After recovery the child should be sent to the country or seashore, 
and have mild general massage. In mild cases the children should be taken 
from school and given a change of air. When arsenic has been given to 
the point where gastric symptoms are manifested, its administration must 
be discontinued, and the following digestive may be given: 

Py Acid, hydrochloric, or dil., 3j; 

Tinct. gentian, comp., 3j; 

Ess. pepsin., 5hj. 

M.S.: A teaspoonful after eating. 

The use of arsenic may be resumed after the tongue is clean. In some 
cases vibration over the spine every other day for ten minutes has been 
followed by satisfactory improvement. 

THE PARALYSES OF INFANCY AND CHILDHOOD 1 

Obstetrical paralysis of the face or arm is caused by injuries inflicted 
during labor, and is discussed in the section of diseases of the new-born. 

Little's disease is a congenital spasmodic paraplegia of the extremities, 
particularly the legs, capable of improvement and cure by general hygienic 
management and mild massage, though if syphilis is the underlying cause, 
mercury should be administered. 

Infantile Spinal Paralysis (Acute Anterior Poliomyelitis.)- — This ail- 
ment is most frequent between the ages of one and four years, and must be 
looked upon as an acute infection localized in the cord. The disease occurs 
sporadically and in epidemics. The onset is usually sudden, with fever, 
vomiting, diarrhoea, and prostration. Paralysis sets in shortly after the 
onset. When children are taken sick in the afternoon, the paralysis is 
generally manifest on the following day. There are no disturbances of 
sensation and the intelligence remains intact. One side or both sides may 
be paralyzed at the onset, but after a few months, even without treatment, 
we find the paralysis limited to a few muscles of one leg or arm. The 



1 See also Neurological Memoranda. 



THE PARALYSES OF INFANCY AND CHILDHOOD 



217 



muscles are soft, never rigid, and show no tendon reflex, thus contrasting 
sharply with the rigidity of cerebral paralysis. Atrophy in infantile spinal 
paralysis is also marked. The lesion affects the growth of the paralyzed 
limb, and the joints become lax. It has been noticed that those muscles 
recover which respond to the faradic current. The total absence of 
sensory symptoms is also characteristic of infantile spinal paralysis. 

Differential Points. — In discriminating between anterior poliomyel- 
itis and multiple neuritis following infectious disease (diphtheria and influ- 
enza), it will be well to remember that in the latter lesion the limbs are 
affected symmetrically, the muscles are tender, and in fact the sensory 
symptoms are severe. Paralysis, atrophy, 
reaction of degeneration, and loss of tendon 
reflex are present in both. 

Treatment. — The object is to increase 
the nutrition of the limb and protect it from 
injury. The paralyzed limb is cold and 
should be well wrapped during cold weath- 
er. Massage, gymnastics, hot and cold 
douches, and the interrupted or galvanic 
current and vibratory massage are indi- 
cated. If a brace is applied, it must be 
light and not cumbersome. Orthopaedic 
surgery has been invoked to overcome the 
paralytic club foot and contractures by 
tendon grafting and shortening of tendons 
and nerve anastomoses, and some note- 
worthy results have been obtained. 

Infantile Cerebral Paralysis with Re- 
tarded Development (Spasmodic Infantile 
Hemiplegia.) — Beginning more or less with 
brain manifestations, fever, delirium, con- 
vulsions, spasm, the paralysis is of the 

hemiplegic type, with rigidity, contracture, and exaggerated reflexes. The 
electrical reactions are normal, and there is no rapid or extreme wasting. 
Athetoid movements are noted in some cases, also posthemiplegic chorea. 
Protracted labor, instrumental injury, asphyxia, acute infection (scarlatina, 
diphtheria, cerebrospinal meningitis), cysts, and areas of softening and 
sclerosis are serological factors. 

Prognosis. — Facial paralysis generally disappears, the leg improves, 
and the arm remains disabled. 

The treatment is the same as in the spinal paralysis, and in cases of 
doubtful origin the patient should have the benefit of the doubt and be given 
an inunction cure. 

Primary Myopathies. — Pseudohypertrophic muscular paralysis and atrophic 
myopathies are forms occurring in late childhood, usually beginning be- 
tween the ages of two and eight and affecting both sexes. Some form of 
motor weakness is generally the first symptom, and the way in which 
the patient raises himself from the horizontal to the vertical position is 
characteristic of the lesion. Owing to weakness of the extensor muscles of 




Fig. 92. — Pseudohypertrophic 
Muscular Paralysis. 
Trying to get up. 



218 



PEDIATRICS 



the knee, he places his hands on the lower part of the thighs and gradually 
raises himself upward by this assistance. The posture and gait are charac- 
teristic. When the patient is standing, the abdomen projects, the back 
is hollow, the buttocks are thrown back, the feet are planted apart, and the 
gait is swaying and waddling. There is feeble response to both currents 
of electricity. 

The prognosis of myopathic disease (atrophy or pseudohypertrophy) 
is not favorable. After the power of standing is lost, the case is practically 




Fig. 93. — Pseudohypertrophic Muscular Paralysis. 
Showing characteristic posture in trying to rise. 



hopeless, but no case should be pronounced hopeless until treatment has 
been persisted in on the following lines and with a view of exhausting the 
"specifics " before we give up all hope: 

Open the bowels to eliminate autoinfection from the intestine. 

Give general mild massage and baths to better the circulation. 

A course of antimalarial treatment, even if the plasmodium is absent 
from the blood, may be given. 



THE PARALYSES OF INFANCY AND CHILDHOOD 



219 



A course of antisyphilitic treatment, with mercury and with potassium 
iodide. 

A course of antirheumatic treatment with sodium salicylate. 

A course of treatment with thyreoid preparations. 

A course of treatment with suprarenal preparations. 

Pott's paralysis is common in childhood. It follows disease of the dorso- 
lumbar vertebrae, and its management is discussed under Orthopaedics. 

Diphtheritic Paralysis. — Postdiphtheritic paralysis may affect the mus- 
cles of the palate, the oculomotor muscles, the diaphragm and respiratory 
muscles, the muscles of the extremities (ataxia), and the heart muscle. 

The diagnosis is easy when the previous occurrence of diphtheria is 
known. Important symptoms are dysphagia, food regurgitation, a nasal 
voice, and a weak, loose cough. Primary paralysis of the palate has occurred 
as late as on the sixty-fifth day, primary oculomotor paralysis on the ninety- 
first day, and primary paralysis of other parts on the fifty-first day. Most 
of the cardiac paralyses occur between the fifth and tenth days; a few cases 
have occurred even as early as on the second day, while this condition has 
occurred in a severe form (that is, ending fatally) in two cases on the fifty- 
fourth day and in one case, which ended in recovery, on the fifty-ninth day. 

The treatment of these conditions is discussed in the chapter on 
Diphtheria. 

Pseudoparalysis in syphilitic, rhachitic, and scorbutic children is fre- 
quently observed. The extremities are affected, the sphincters are free, 
and the electrical examination is negative. In syphilis and scurvy pain 
is excited by moving the limb. In rhachitis the muscular weakness simu- 
lates paralysis. 

The treatment is hygienic and dietetic, also specific in cases of known 
or suspected syphilis. 

Syphilitic Paralysis of Peripheral Origin. — The diagnosis of this condi- 
tion rests upon the fact of the integrity of the bones and upon the modified 
electrical reaction. When the signs of syphilis are not evident, the distinc- 
tion from infantile paralysis is made by the fact that the latter occurs 
suddenly, with fever, generalization of the paralytic phenomena, and 
absence of pain. 

Painful paralyses, or paresis in neuritis, may occur in children as well 
as in adults, usually from infection. The diagnosis is made from the pain 
and the rapid onset of the affection conjoined with the fact that there 
is no lesion of the joints or bones. 

Paralysis in the convalescent period of measles is of the paraplegic type, 
lasts about six weeks, and usually ends in recovery. 

Choreic paralysis is usually of the hemiplegic or monoplegic form, and 
most frequently occurs while chorea is present or during convalescence. 

Friedreich's disease, or hereditary ataxia, does not present phenomena 
of motor incoordination; there are nystagmus and disturbances of speech. 
It is not a congenital affection. The fulgurating pains, anaesthesia, and 
trophic disturbances of locomotor ataxia are wanting. Vertigo is present. 

Painful Paralysis of Young Children. — It is occasionally noticed that 
after a jerk or a twist an arm or leg is perfectly flaccid, and the children 
cry when the least movement is made, although there are no anatomical 



220 



PAEDIATRICS 



changes to be observed. Passive movements are perfect and ecchymoses 
are absent. Recovery is rapid, occurring in from one to eight days. Such 
injury is probably of the nature of traumatic neuritis, and mild daily massage 
is all the treatment that is necessary. 

Hysterical Paralyses. — In this form the reflexes are not abolished and 
the diagnosis is made by exclusion. 

The Causes which may Retard or Prevent Walking in Children. — The 
majority of children begin to walk between the tenth and sixteenth months, 
a few at eight months, and the most backward at the end of the second year, 
Any child who is unable to walk by the end of the second year will usually 
be found to be the subject of a pathological condition. The diseases which 
render a child unable to walk, or retard or otherwise interfere with that 
function, are rachitis, cerebral atrophy, cerebral sclerosis, hydrocephalus, 
meningitis, spasmodic hemiplegia, cerebral or cerebellar tumors, amyo- 
trophic lateral sclerosis, hereditary ataxia, infantile paralysis, chorea, and 
sometimes hysteria. In the diseases of the muscles there are also two which 
have a decided influence in interfering with the function of walking — pseudo- 
hypertrophic paralysis and a form of myopathy which begins in the lower 
limb. Lesions of the bones and joints have also an important bearing 
in this direction — namely, fractures, congenital or traumatic luxations, 
arthropathies, club feet, Pott's disease, and rhachitis. 

MENINGITIS IN CHILDREN 

The meninges respond to irritation like other serous membranes, and 
may become the seat of primary or secondary inflammation, accompanied 
by serous or purulent effusion. The same species of microbe which pro- 
duces a pneumonia or pleurisy may start a meningitis or synovitis, according 
to its localization. The infecting agent may reach the meninges through 
the blood or by extension from the nasopharynx, the ear, or the eye. 
Meningeal symptoms, such as delirium and slight rigidity of the neck, are 
often observed in acute infectious diseases. These are toxic phenomena 
(toxaemia) , and must not be confounded with true meningitis. 

Simple acute meningitis is an infection of the pia mater by various 
microorganisms, including the pneumococcus lanceolatus. It may be primary 
or secondary to any form of infectious disease. The infecting agent may 
reach the pia through the circulation, or may be communicated by extension 
of a neighboring inflammatory process. The exudate may be serous or 
purulent. When the exudate is absorbed, the membrane may remain 
thickened, as in pleurisy, and imbecility or idiocy result. 

The cerebrospinal meningitis is distinct clinically from the first mentioned 
variety, on account of its localization, as shown by the name, and because 
it shows a higher percentage of recoveries than any other variety of menin- 
gitis. It is looked upon as a diplococcus invasion of the membranes of 
the brain and spine, and occurs sporadically and epidemically. 

Tuberculous meningitis is an infection of the meninges by tubercle 
bacilli in the form of gray miliary tubercles. It is of frequent occurrence 
in children of two, four, or six years of age, and is also seen in older children. 
It is generally secondary to tuberculosis of some other organ, but clinically 



MENINGITIS IN CHILDREN 



221 



it impresses one as starting primarily in the brain. Often there is a history 
of traumatism which seems to be the starting point of the disease. Infection 
takes place through the circulation or by extension from tuberculous ear 
disease or from tuberculous glands. The nasopharynx is believed to be a 
portal of entrance. 

Symptoms and Signs of Meningitis in General. — General malaise, 
drowsiness, vomiting, constipation, stiff neck and back, loss of control of 
the bladder and rectum, convulsions, delirium, coma, set eyes. 

The temperature ranges from 101° to 105°, 106°, and 107° F., or higher. 
The pulse at first is rapid, then irregular and slow. Cheyne-Stokes respira- 
tion is often observed. 

Symptoms of Tuberculous Meningitis.- — First stage. The onset is usu- 
ally gradual. General irritability, loss of appetite and weight, pallor, low 




Fig. 94. — Cerebrospinal Meningitis. 



fever, and poor sleep are noted. These symptoms may extend over two 
or three weeks. 

Second stage. Excitation, vomiting, convulsions, irregular pulse and 
temperature, tache cerebrale, rigidity, tremor, and contracture. 

Third stage. Depression. Large, rigid pupils, slow, arrhythmic pulse, 
sighing respiration, strabismus, oscillating eyeballs, injected conjunctiva, 
hydrocephalic cry, Cheyne-Stokes respiration, delirium, convulsions, death. 

Differential Diagnosis. — In discriminating between the three forms 
of meningitis it will be well if we bear in mind that all the symptoms 
spoken of are the usual ones of a group of pathological conditions which 
we class under the heading of encephalo-meningitis, the tetiology of which 
embraces a variety of causes. 

1. Primary microbial infection, including the tuberculous variety. 

2. Secondary microbial infection, following any form of acute or chronic 
infection, including syphilis. 

3. Extension of a neighboring inflammatory process in the ear or nose, 
panophthalmitis, intracranial abscess, tumors, etc. 

When we are face to face with illness in which meningeal symptoms 
are noticeable, the first practical and important point to decide is as to 



222 



PEDIATRICS 



whether or not there is meningitis. The question cannot be decided by 
taking into consideration any group of symptoms. A careful weighing 
of all the evidence is necessary. 

Vomiting, delirium, muscular rigidity, as symptoms of toxaemia, are 
just as pronounced in some cases of pneumonia, influenza, or eruptive fevers 
as in acute true cerebral or spinal meningitis. Malaise, vomiting, constipa- 
tion, low muttering, grinding of the teeth in sleep, injected conjunctiva, 
irregularity of the pulse, and sighing respiration are symptoms of long 
standing intestinal inertia and autoinfection as well as symptoms of tuber- 
culous meningitis. 

In meningitis we can generally elicit the tdche meningitique, or Trous- 
seau's sign, by drawing the finger nail sharply over the skin. Owing to 
vasomotor disturbances the red irritation mark comes slowly and disap- 
pears slowly. 

Kernig's Sign. — In cases of meningitis it is usually impossible for a 
patient lying on his back to flex the thighs upon the body without flexing 
the knee at the same time, and complete extension of the legs is impossible. 




Fig. 95. — Meningitis. 



Both Trousseau's and Kernig's signs are occasionally found in patients 
not suffering from meningitis, and their absence does not positively exclude 
the diagnosis of meningitis. 

Spinal Puncture. — The cerebrospinal fluid obtained by puncturing 
the spine is cloudy or turbid in acute meningitis. In several cases of menin- 
gitis the writer has withdrawn pure pus by spinal puncture repeatedly, 
one child living three weeks in this condition. In tuberculous meningitis 
the fluid is very clear. The tubercle bacilli can seldom be found in the 
fluid by microscopical examination. If present, they are detected by the 
culture and inoculation tests. 

The prognosis is grave. Meningitis may progress for weeks and ter- 



MENINGITIS IN CHILDREN 



223 



minate in recovery or death. When recovery occurs, blindness, muscular 
paralysis, speech defects, and defective intellect may remain. Meningitis 
may terminate in complete recover}'. In the so called intermittent cases of 
cerebrospinal meningitis the prognosis is not unfavorable, and patients may 
recover completely from a clinical standpoint. 

In tuberculous meningitis the prognosis is unfavorable. 

The usual types of cerebrospinal meningitis are the mild, subacute, 
rapidly fatal, intermittent, and chronic. 

Treatment of Meningitis. — After the diagnosis is established, the treat- 
ment is symptomatic. Ice coil to the head; warm mustard baths, cool 
sponge baths. Fever diet: Milk, gruels, broths, tea, beef tea, eggs. In- 
unctions of mercurial or Crede ointment, 1 drachm twice daily. A daily 
enema of soap water or salt water, 1 drachm to 1 pint. Catheterism of 
the bladder in cases of retention of urine. Feeding by gavage in coma. 
Feeding per rectum. Spinal puncture to relieve pressure symptoms. 
Stimulation p. r. n. Tincture 
of iodine to check vomiting, 1 
drop in sweetened peppermint 
water every two to three hours. 
Sodium salicylate, 5 to 20 
grains, in water, per rectum, 
three times a day. 

A so called fever diet is 
essential in all febrile disease 
or conditions. The food should 
be fluid or semisolid, so as not 
to overtax the feeble digestive 
apparatus or leave a large resi- 
due in the intestine for decom- 
position, which would be apt 
to favor autointoxication or 
local irritation. 

For older children, who no 
longer take the bottle, we may 
select food from the following 
list: Water, toast water, fari- 
naceous water, gum arabic 
water, white of egg in water, 
peppermint tea, imported gin- 
ger ale, black tea, milk, mat- 
zoon, kumyss, buttermilk, whey, sterilized, Pasteurized, or peptonized 
milk, malted milk, beef broth, mutton broth, chicken broth, with and 
without eggs, beef jelly, soups, gruels, cornstarch pap, pea soup, burnt 
flour soup, eggnog, tropon or somatose in peppermint tea, custard, ice 
cream, water ices, orange or pineapple juice, unfermented grape juice, etc. 

Indications for Gavage. — When the patients refuse to take food 
or are comatose and when rectal alimentation is inadequate. 

1 Seibert claims excellent results from large doses of sodium salicylate 30 grains three 
times a day per rectum. 




Fig. 96. — Spinal Puncture. Forward Bicycle 
Position. 



224 



PEDIATRICS 



Rectal Alimentation. — Nutrient Enemas. — Feeding by the rectum is 
useful in feeble digestion and in cases in which food is not tolerated by the 
stomach or to supplement a feeble stomach or in inability to swallow, etc. 

Antipyretic Measures. — Where the temperature is very high a warm 
bath (95° to 100° F.) may be given, and cold water may be added 
to the bath until the temperature is reduced to 75° F., or a cool sponge 
bath may be given several times a day, supplemented by an ice bag to the 
head. Drug antipyretics are hardly ever called for. 

Cerebral restlessness is best treated by cooling baths and by chloral 
hydrate, and bromide of sodium by the mouth or per rectum. 

Stimulation is best accomplished by means of enteroclysis (high enemata 
of salt water at 110° to 120° F.). Of stimulant drugs, we may employ 




Fig. 97. — Ice Water Coil in Meningitis. 



camphor and strychnine. Camphor may be given in one-half to one grain 
doses, hypodermically, dissolved in oil (one fifteenth). 

Local Treatment. — In meningitis local treatment has been attempted 
by the author by injecting iodoform, potassium iodide, and sodium salicylate 
into the subarachnoid space without beneficial results. 1 Patients with 
cerebrospinal meningitis frequently recover after the administration of 
salicylate of sodium and bromide of potassium internally. 

In 1902 Seager, of Lisbon, suggested local treatment in cerebrospinal 
meningitis by means of lumbar puncture and injections of 10 c.c. of a 



1 Trans, of the Am. Peed. Soc. 



HYDROCEPHALUS 



225 



1 per cent solution of lysol. It has not proven of value in the author's 
experience. 

HYDROCEPHALUS 
Hydrocephalus may be congenital or acquired. 

Congenital Internal Hydrocephalus. — We do not know the cause. It has 
been noticed in several members of the same family. Syphilis is an un- 
doubted factor. It is principally the lateral ventricles which are affected, 
and they may be so distended as to thin out and stretch the cerebral cortex 
over them to less than a quarter of an inch in thickness. The skull becomes 
enormously enlarged, the su- 
tures and fontanelles are widely 
distended, the bones of the 
cranium are thinned, and the 
orbital plates may be so pressed 
forward as to cause exophthal- 
mus. The distending fluid is 
clear and contains traces of 
albumin and salts and ■ some- 
times urea. 

Labor may be interfered 
with by the large head. In 
some cases the head does not 
become enlarged until several 
weeks after birth. Irritability 
and restlessness are prominent 
symptoms. The child is usu- 
ally not bright mentally and 
most generally shows some 
degree of imbecility. The legs 
may be feeble and show ex- 
aggerated reflexes, making it 
difficult for the child to learn 
to walk. Strabismus and optic 

nerve atrophy may develop, Fig. 98. — Hydrocephalus. 

and nystagmus is usually seen. 

Ultimately there are convulsions, vomiting, and coma, and the child sel- 
dom lives to be more than three or four years old. 

Acute hydrocephalus (serous meningitis), alluded to under simple 
meningitis, is often secondary to a basilar meningitis. There is rarely very 
great distention, about three or four ounces of water being present usually. 

Acquired Internal Chronic Hydrocephalus. — The causes are compression 
or obliteration of the straight sinus or of the passage from the third to the 
fourth ventricle by a tumor or some obstructing local inflammation fol- 
lowing a meningitis. Some cases arise without known causes (serous 
apoplexy) . 

Symptoms. — They are obscure; headache, optic neuritis proceeding 
to atrophy, and attacks of stupor are usually noticed. The head does 
16 




226 



PEDIATRICS 



not enlarge, and there are no localizing symptoms. The diagnosis is seldom 
made during life. 

Treatment of Hydrocephalus. — This is largely mechanical. Gradual 
compression may be made by means of strips of adhesive plaster crossed 
in various ways. The symptoms of pressure may be relieved by withdraw- 
ing small quantities of fluid from the ventricles from time to time by means 
of an aspirating needle. Lumbar puncture of the subarachnoid space, 
permitting a slow escape of the fluid, may be practised without risk to the 
cord and without much danger of collapse. Medicines are apparently use- 
less, although mercurial inunctions and potassium iodide may be tried in 
cases of suspected syphilis. Drainage by means of a silver cannula con- 
necting a ventricle with a vein has been practised without satisfactory 
results. 

Chronic external hydrocephalus is exceedingly rare, and probably is 
always secondary. It is associated with some congenital malformation 
or atrophy of the brain, and may follow meningeal haemorrhage or pachy- 
meningitis. The fluid is confined beneath the dura mater, which, when 
incised, allows of the escape of a few ounces, sometimes as much as a pint. 
There is flattening of the convolutions, and sometimes there is atrophy. 
Some internal hydrocephalus may be present. The fluid may cause enlarge- 
ment of the head, separation of the sutures, and in fact most of the appear- 
ances of "the internal variety. As a rule, it is not severe enough to give rise 
to any decided symptoms. 

DISORDERS OF SPEECH; STAMMERING, STUTTERING, AND LISPING 

When disorders of speech take their origin in the nerve centres, treat- 
ment or training will avail but little. When tongue tie, adenoid vegetations, 
irregular teeth, or cleft palate are causes, the stammering, stuttering, and 
lisping are easily remedied. Systematic teaching and training may over- 
come speech defects when they are due to a failure on the part of the vocal 
organs to cooperate with those of articulation. Tremor following severe 
acute illness or nervous shock or overwork or general debility will require 
constitutional treatment. 

HYSTERIA IN CHILDREN 

Hysterical Paralyses, Aphonia, Neuralgia, Contractures, Hyperesthesia, 
Holding the Breath. — Psychical, sensory, and motor phenomena of a morbid 
character are common from infancy through childhood in ansemic children 
having neurotic parents or neurotic surroundings, in the offspring of al- 
coholics, and as complications of acute disease. Hysterical manifestations 
are possible as soon as the child has acquired the capacity to receive im- 
pressions and develop conceptions. 

In discriminating between hysteria and organic disease it is a great 
mistake to underestimate the shrewdness of a child, and the physician will 
readily deceive himself in diagnosis and thwart himself in the way of moral 
treatment if he unthinkingly makes the child or its hysterical mother a 
confidante of his views. 




Fig. 101. — Same child. Four weeks after treat- Fig. 102. — Same child. Ten weeks after 

ment with thyreoid. treatment with thyreoid. 



Figs. 99-102. — Sporadic Cretinism. (Case of Dr. H. B. Sheffield.) 227 



228 



PEDIATRICS 



Hysterical and epileptic conditions blend and alternate, and the line 
of demarcation is exceedingly vague. It is therefore useless to go into 
details regarding diagnosis, because such matters will be decided by the 
acuteness and tact of the medical attendant, and not by a pen picture of 
conditions by no means clear cut. 

Prognosis is good, but there is a tendency to relapse. 

Treatment. — Rational hygiene and the handling of hysterical children 
by a kindly, firm, and intelligent woman is a conditio sine qua non of success- 
ful management. Self-control must be developed. Massage, cold baths, 
and gymnastics are indicated, and punishment is often a necessary feature 
in the treatment. As chronic intestinal indigestion is at the bottom of 
many ailments, every effort should be made to secure normal digestion for 
the child. 

MENTAL DEFECTS FROM ARRESTED DEVELOPMENT 

Idiocy; Imbecility; Cretinism; Mutism 

The idiot represents the lowest expression of human intelligence. In 
the scale of mental power and activity the imbecile stands between the 
idiot and the feeble minded, and about 5 per cent of imbeciles present 
the so called Mongolian type of imbecility. Such conditions are congenital 
or acquired. Imbeciles and feeble minded children may be developed 
along the line of their unimpaired faculties by special training if removed 
from the influence of neurotic parents. The mentally deficient are divided 
into the three following classes: 1. Congenital mental deficiency in its various 
forms of microcephalus, hydrocephalus, the Mongol type, scrofulous cases, 
birth palsies with athetosis, cretinism, and primarily neurotic cases; 2. 
Developmental cases; 3. Accidental or acquired cases, consisting of trau- 
matic, postfebrile, emotional, and toxic varieties. 

Mutism may depend upon absolute deafness, mechanical defects of the 
speech apparatus, or mental defects. 

It is not generally realized how much moderately deaf children are 
handicapped in the acquisition of language and general information. 

Cretinism is faulty development in connection with some abnormality 
of structure or function of the thyreoid gland. Thyreoid medication has 
achieved some remarkable results in cretins, and has been of some benefit 
in imbeciles and feeble minded children in which the signs of cretinism are 
absent. From two to five grains of the powdered desiccated sheep's thyreoid 
gland may be given for a long time. (See also Diseases of the Ductless 
Glands.) 

Amaurotic family idiocy is the unfortunate name given to a symptom 
complex of brain degeneration in which inability to hold the head up and 
blindness are the marked features. Children so afflicted generally die 
before the age of two. The treatment is symptomatic and unavailing (see 
also Neurological memoranda). 



CHAPTER IV 



THE DIGESTIVE SYSTEM 

NUTRITION AND DIET 

Synopsis : Introductory Remarks. — Digestibility of Food. — The Absorption of Food. — 
Constituents of Food. — Fuel Values of Food. — Tables of Calories (Fuel Values). — 
Practical Dietetics. — Fluid Diet ; Soft Diet ; Full Diet ; Restricted Diet ; Fever Diet, 
etc. — Stimulants and Beverages: Alcoholic, Non- Alcoholic, Mineral Waters. — Pre- 
digested Food. — Concentrated Food. — Systems of Diet: Banting, Ebstein, Oertel, 
Schweninger, Weir Mitchell. — Vegetarianism. — Exercise and Diet. — Tobacco and 
Digestion. 

INTRODUCTORY REMARKS 

The general practitioner is constantly confronted with the question of 
what foods shall be allowed or not allowed in the management of various 
acute and chronic disorders, and there is probably no subject related to 
the practice of medicine in which there is a greater lack of agreement than 
that of nutrition and diet. Nervous dyspeptics are kept upon a liquid diet 
until they are wrecks, young children and adults are fed with pancreatized 
food until the gastroenteric tract is foul and putrid, green salads are pro- 
hibited to convalescents whose system craves them, and in general the 
patient encounters such a complexity of diet regulations as to thoroughly 
bewilder the unfortunate individual who runs the gamut of a number of 
medical men. For this reason the writer has thought it proper to devote 
some space to practical dietetics. In developing rational dietetics we are 
guided by our known principles of metabolism and the fuel value of food 
and by the maxim that the true principles of dieting in disease must be 
in accordance with the dictates of common sense. 

Nature's indications as regards diet relate to appetite and the sense of 
taste as regulated by individual experience. Natural craving for a certain 
food is not necessarily morbid in disease and should not, as a rule, be opposed. 
To the healthy person the natural demands of the appetite are the best 
guide for quantity and quality, and a mixed animal and vegetable food is 
the best diet. 

In disease instinct may fail to express the proper needs of the system, 
and the knowledge and judgment of the physician will be called for. 

The exigences of life have established the routine of three meals a day, 
but in many eases dyspeptics of sedentary habits might with profit go back 
to nature and eat only when they had the desire for food. 



229 



230 



THE DIGESTIVE SYSTEM 



REMARKS ON DIGESTIBILITY OF FOOD 

Beef possesses great nutritive power and furnishes the most palatable 
and appetizing broth. Salted meat is less nutritious than fresh, because 
the brine extracts from the muscular tissue some of its nutritive principles. 
Next to beef in nutritive value come mutton and venison, then the flesh of 
fowls, the various kinds of game birds, and lastly fish. The difference be- 
tween white meat and dark meat as regards digestibility is too trivial to 
be of practical importance. Fish is slightly nutritive, but easily digestible. 
Its exclusive use would produce a diminution of the muscular force, paleness 
of the tissues, and all the signs of subalimentation. The flesh of shell fish 
is hard of digestion. Roast meat is more digestible than boiled meat. Eggs 
very slightly cooked are more digestible than white meats. Of vegetables, 
the succulents are the most digestible. New bread is heavier than stale 
bread. The aliments to which the cook's art gives a liquid or semiliquid 
form are, in general, more digestible than others. Both reason and expe- 
rience show that Nature's liquid and semiliquid foods, milk and eggs, are 
particularly adapted for a feeble digestion during the course of febrile dis- 
ease. Of the vegetable class, lentils, beans, and peas are the most nourish- 
ing. Fruit, when perfectly ripe, is easy of digestion, because the juice of 
fruit consists of pure grape sugar (glucose) and water, and it is in the form 
of grape sugar that all starchy food is finally absorbed into the system. 

THE ABSORPTION OF FOOD 

Although we possess considerable knowledge regarding the absorption of 
food and the quantities necessary to sustain life, our knowledge of the ul- 
timate processes of assimilation and dissimilation is meagre. The animal or- 
ganization requires constant feeding with water, salts, and organic materials 
— proteids, carbohydrates, and fats. The proteids are tissue builders. 
The carbohydrates are energy producers. Without proteid material in 
some form life cannot be sustained. The amount necessary depends upon 
individual disposition and upon individual expenditure of heat and force. 
An inadequate supply of food from loss of appetite or poverty leads to 
inanition; and, if the animal organism does not get the adequate amount 
of food, it burns its own material. Thus some parts of the organism are 
sacrificed to preserve the whole. The first to be used up are the fat and sugar 
(glycogen), and finally the albuminoids, or living tissue. Fat and muscle 
go first, and subsequently skin, liver, bone, heart, and central nervous 
tissue. The surplus of nitrogenous (proteid) material absorbed by the 
gastroenteric tract leaves the body through the kidney (urea). Thus 
it is not possible to increase living tissue by simply overfeeding with proteids. 

The carbohydrates furnish the living energy of the body. A surplus 
of such foods is lost partly through an overproduction of heat, but is prin- 
cipally hoarded in the body as fat and glycogen unless oxidized and thrown 
off by exertion. It is suspected that a large quantity of water favors an 
increase of fat, but this is by no means established as a fact. 

It is difficult to establish a line of demarcation between normal and 
pathological adiposity, and clinically we speak of the latter in connection 
with certain subjective complaints, such as dyspnoea, sweating, a feeling 



THE COMPONENTS OF FOOD 



231 



of weakness, heart palpitation, and general anaemia. Alcohol in all forms 
(but particularly as beer and whiskey) is easily burnt up, prevents fat 
oxidation, and produces a habit of indolence. Thus for simple forms of 
fat deposit a regulation of diet and exercise is sufficient. But some people 
do not get fat by overeating, and others do not get lean by undereating. 
There must be some factor influencing metabolism outside of a lack of 
harmony between the quantity of food and the energy expended (perhaps 
suboxidation). An undue loss of proteids and fats is observed in fever, 
carcinosis, tuberculosis, anaemia, pneumonia, and acute dyspnoea, probably 
due to the formation of toxic products in such diseased conditions. The 
thyreoid gland increases fat and proteid metabolism. 

A healthy organism will thrive on plain food and assimilate the nutrient 
qualities of the crudest material. A feeble digestion will require concen- 
trated and easily digested food. A thorough knowledge of the chemistry 
of digestion and assimilation is valuable, but its practical application is 
limited, owing to the great complexity of the subject. The gastroenteric 
tract must not be likened to a test tube with a final and definite chemical 
reaction of its contents. Nature has the power of vicarious selection, and 
seeks her nutritional elements from all sources. 

The Components of Food 

Perishable, or organic, food may be divided into nitrogenous and non- 
nitrogenous. 

1. We have (a) albuminates and gelatinous substances from the animal 
and (b) gluten and legumin from the plant. 

2. We have (a) hydrocarbons, as fats, oils, butter, etc., and (b) carbo- 
hydrates, as starch, sugar, and vegetable acids. 

The final product of albumin in the gastroenteric tract is peptone. The 
transitional stages of albumin digestion by means of pepsin, hydrochloric 
acid, and pancreatic juices are designated acid albumin, hemialbumin, and 
peptones. Peptone, after reabsorption, plays its role as a tissue builder 
by the synthetic process. 

The fats are slightly changed in the stomach, but the principal assault 
upon fat takes place in the intestines by means of pancreatic juice, bile, 
and bacteria, and the final products are triglycerides, fatty acids, and 
neutral soaps. 

Absorption of fat and its components takes place in the intestines 
through epithelia, and then fat is deposited in various parts of the body. 

The Carbohydrates. — The sugars taken into the gastroenteric tract are 
in a state ready for absorption. Starchy food must be turned into absorbable 
sugar by means of dextrose, which is found in the saliva and pancreas. 
Then starch is converted into dextrin, maltose, and grape sugar, and what 
is not destroyed by fermentation in the gastroenteric tract is absorbed 
into the portal circulation. The inorganic constituents of food are the 
various salts and water. To summarize, we may say: Milk, eggs, meat, 
fowl, and fish are rich in albumin. Bread, cereals, potatoes, beans, and 
peas contain starch and albumin. Fruits, spinach, lettuce, tomatoes, 
celery, etc., supply vegetable acids, salts, sugar, etc. 



232 



THE DIGESTIVE SYSTEM 



The Fuel Value of Food. — Heat and muscular power are forms of force 
and energy. The energy is developed as the food is consumed in the body. 
The unit of measurement is the calorie, this being the amount of heat 
which will raise the temperature of a pound of water 4° F. (1 kilo of water 
1°C). 

1 gramme of protein = 4 calories. . 1 lb. of protein = 1,860 calories. 

1 gramme of starch or sugar = 4 calories. 1 lb. of starch or sugar = 1,860 calories. 

1 gramme of fat = 9 calories. 1 lb. of fat = 4,220 calories. 

A man at rest requires about forty calories per kilo, of body weight. 
A man weighing sixty kilos requires two thousand calories in twenty-four 
hours. Thus, in twenty-four hours, a man requires: 

Albumin, 50 grms. = 200 calories. 

Fat, 50 " = 450 " 

Starch or sugar, 400-500 " = 1,600 " 

Total 2,250 " 

The approximate requirement for a growing child is not found by multi- 
plying its weight in kilos by forty (calories). During the first year of its 
life a child which is thriving gains half an ounce a day and requires on an 
average a quart of milk. One quart of milk represents seven hundred calo- 
ries. In the healthy individual the normal requirements of food or heat 
energy will depend upon the amount of expenditure in motor force, mental 
force, and sexual (reproductive) force. 

CALORIES, OR HEAT UNITS, REQUIRED IN FOOD PER DAY 

(Compiled by Atwater) 

Children, to one and a half years, 767 calories. 

" two to six years 1,418 

" six to fifteen years, 2,041 

An aged woman, 1,860 

An aged man, 2,477 

A woman at moderate work or light exercise, 2,400 

A man at moderate work or light exercise, 3,000 

A man at hard labor, 3,500 

One day solid food rations (Mrs. E. H. Richards): 

Bread, 16 oz 1,200 calories. 

Meat 8 " 243 

Oysters, 8 " 70 

Cocoa, 1 " 135 

Milk, 4 " 75 

Broth, 16 " 613 

Sugar, 1 " 112 

Butter, \ " 118 



2,572 

Heat Values and Food Values. — According to Armsby the food value of 
a nutrient a? a source of energy to the organism is not measured by the 



FORCE PRODUCING VALUE, OR CALORIES PER POUND 233 



total energy which it can liberate as heat in the body, but by the part of 
this energy which is available to the organism for physiological uses. The 
remainder of the fuel value simply serves to increase the generation of heat 
in the body, a result which may be advantageous or the reverse, according 
to the surrounding conditions. 



Atkinson's table of nutrients and calories of different people 





Proteids. 
Grms. 


Fats. 


CH. 


Total. 


v_yci i y 1 1 ico. 


Sewing girl, London. Wages, 93 


cents a 












week 




53 


33 


316 


402 


1,820 


Factory girl, Leipsic, Germany. 


Wages, 












$1.21 a week 




CO 


OO 


6V I 


4Ub 


1,940 


Poor laborer, Lombardy, Italy. 


Mostly 












vegetable diet 


82 


40 


362 


404 


2,192 


Trappist monk in cloister. Little 


exercise. 
















68 


11 


469 


548 


2,304 


German miner. Severe work 




133 


113 


634 


880 


4,195 


Brickmaker, Italian, at contract work, 












Munich 




187 


117 

117 


675 


959 


A £Z A~1 

4,041 


Brewery laborer, Munich. Severe work. 












Exceptional diet 




223 


113 


909 


1 ,245 


5,692 


German soldier, peace footing 




114 


49 


480 


633 


2,798 


German soldier, war footing 

German soldier, extraordinary 




134 


58 


489 


681 


3,093 


exertion. 












Franco-Prussian War ■. 




1 C7 

10/ 


ZoO 


ool 


1 to 


4,00.6 


Factory operator, Massachusetts 




127 


186 


531 


844 


4,428 


Private well to do family: 


















129 


183 


467 


779 


4,146 


Food eaten 




128 


177 


466 


771 


4,082 


Eastern States : 


















138 


184 


622 


944 


4,827 






181 


292 


557 


1,030 


5,742 


Clubs : 














Food purchased 




115 


163 


480 


738 


3,874 


Food eaten 




104 


136 


421 


661 


3,417 


Teamster with hard work, Boston 




254 


363 


826 


1,443 


7,804 


Brickmaker, Massachusetts 




180 


365 


1,150 


1,695 


8,848 


U. S. Army ration 




120 


161 


454 


735 


3,851 


U. S. Navy ration 




143 


184 


520 


847 


4,998 



As a matter of practical interest, the following calorie tables are re- 
produced (Woodruff, Garrison Rations): 



FORCE PRODUCING VALUE, OR CALORIES PER POUND 

Bacon, fat, or lard, 3,080 calories per lb. 

Beans, 1,615 " 

Salt pork, fat, 3,510 " 

Sugar, 1,820 " 

Flour, 1,644 " 

Beef, 1,460 " 

Potatoes, raw, 375 " 

Onions, 225 " 

Oatmeal, 1,850 " 

Corn meal, 1,645 " 

Tapioca or cornstarch, 1,820 " 



234 



THE DIGESTIVE SYSTEM 



Dried apples, 

Butter, 

Syrup, 

Rice, 

Canned corn, 

Canned tomatoes, 

Macaroni, 

Milk, fresh, 

Condensed milk,. . 

Peas, 

Raisins, 

Cheese, 

Prunes, 

Cabbage, 

Ham, , 

Canned apricots, . 

Barley, 

Chocolate, 

Sausage, 

Oysters, 

Canned salmon, . . 

Crabs, 

Crackers, 

For the convenience of the general practitioner, the writer herewith 
furnishes a list of calories compiled from many sources which may be of 
aid in selecting a rational dietary for patients and in estimating the caloric 



value of food taken or prescribed: 

Calories. 

1 egg, 80 

1 quart of milk, 675 

100 grammes of milk, 60 

100 " skimmed milk, 40 

100 " cream, 220 

100 " buttermilk, 40 

100 " ham, 400 

100 " ham and eggs, 250 

100 " wheat bread (toast), 260 

100 " zwieback, 360 

100 " sweet rice cake, 420 

100 " plain cake, 375 

100 " butter, 800 

100 " beef (raw), 120 

100 " " (roast or stewed), 220 

100 " veal cutlets, 230 

100 " " " (raw weight), 140 

100 " chicken (raw weight), 106 

1Q0 " squab ( " " ) -. . . 100 

100 " calves' brains, 140 

100 " fish (raw weight), 100 

100 " oysters (raw weight), 20 

100 " rice, boiled in milk, 175 

100 " mashed potatoes with buttc, 127 

100 " spinach (rich), 165 

100 " puree of beans, 190 

100 " fresh beans, 40 



1,418 calories per lb. 



3,615 " 


tt 


1,023 " 




1,630 


tt 


345 " 


tt 


80 


tt 


1,406 " 


tt 


418 " 


tt 


1,595 


tt 


1,565 


tt 


440 


a 


1,620 " 


tt 


140 " 


it 


155 " 


tt 


1,950 " 


it 


460 


tt 


1,820 


tt 


2,650 


a 


2,065 " 


tt 


230 


tt 


965 


tt 


526 


tt 


1,920 


tt 



PRACTICAL DIETETICS 235 

Calories. 

100 grammes of asparagus, 20 

100 " farina, 290 

100 " omelette, 240 

100 " maccaroni, 350 

100 " caviar, 133 

100 " fruit jelly, 90 



Physiological economy in nutrition, according to Professor R. H. 
Chittenden, means temperance and not prohibition and full freedom of 
choice in the selection of food. Food requirements vary with changing 
conditions, and the requirements of proteid food are about one half of the 
amount generally consumed. Excess means not alone waste, but unneces- 
sary strain and waste of energy to get rid of the excess. Bodily equilibrium 
requires less than 3,000 calories a day under ordinary circumstances, with 
only 16 to IS grammes of nitrogen a day in the form of proteid. 

PRACTICAL DIETETICS 

Dieting is the systematic regulation of diet for hygienic or therapeutic 
purposes. For all practical purposes the various forms of diet will admit 
of a simple classification, viz.: 1. A liquid diet for acute febrile disease; 
2. A light diet for convalescence in febrile disease; 3. A restricted diet for 
subacute and chronic indigestion and malnutrition from whatsoever cause; 
4. A special diet, as for gout, diabetes, children, etc. 

Fluid Diet. — Selections may be made from the following lists: 
Water. — Cold, hot, aerated, flavored, toast water, sugar water, soda 
water. 

Soups. — With or without egg or cereals, etc., burnt flour soup (excellent 
in diarrhoeas), slimy soup of oatmeal or barley with and without egg, may 
be seasoned with celery salt. Bouillon, beef tea, meat juice, clam broth, 
oyster juice, mutton broth, and chicken broth have low nutritional value 
unless they contain cereals, rice, barley, sago, or eggs. 

Gruels. — Arrowroot, barley, cracker, diabetic, farina, Indian meal, 
oatmeal, rice, rice creamed, gruels dextrinized, gruels peptonized. 

Milk. — Raw, plain, with salt, with lime water, with Vichy, sterilized, 
Pasteurized, peptonized, buttermilk, kumyss, matzoon, kefir, whey, eggnog, 
white of egg in water, milk punch, malted milk. 

Milk Cure. — An exclusive diet of milk or diluted milk may be desirable 
in the following conditions or diseases: In infancy for the first eight 
months; in typhoid fever in the absence of tympanites; in acute and 
sometimes in chronic Bright's disease; in acute pyelitis; in chronic gastric 
catarrh; in gastric ulcer and carcinoma; in neurasthenia; in scarlatina; in 
the Weir Mitchell rest cure. 

Other articles of fluid diet are gum arabic solution (in water) , chocolate, 
cocoa, digestible cocoa, ice cream, water ices, Roman punch, scraped ice, 
orange juice, pineapple juice, unfermented grape juice, non-alcoholic malt 
liquors, liquid peptonoids. 

Light, or soft, diet (convalescent diet) embraces liquid diet plus meat, 
jelly, and calves' foot jelly; eggs, scrambled, soft boiled, poached, raw; 
scraped meat or beef; oysters, raw, stewed; tomato ketchup; green salads, 



236 



THE DIGESTIVE SYSTEM 



with vinegar or lemon juice dressing; lettuce; watercresses ; asparagus tips; 
crackers; toast; zwieback; Albert biscuits; sponge cake; Graham crackers; 
saltines; bread (not fresh); rolls; puddings: rice, farina, cornstarch, tapioca, 
custard; purees and bisques: asparagus, bean, celery, chicken, clam, onion, 
oyster, pea, tomato; jellies: beef aspic, chicken aspic, calves' foot, orange, 
sherry, champagne, lemon, wine, cranberry; stewed fruit; stewed prunes, 
baked apples, apple sauce; oranges, grape fruit; stewed tomatoes, spinach, 
rhubarb; preserves, currant jelly, fruit jelly; Charlotte russe, blanc mange; 
oyster cocktail, egg souffle; chocolate in cakes; ham (raw), tongue, ham and 
egg omelette; calves' brains, sweetbreads; mock turtle soup; macaroni 
with tomato sauce; anchovy paste or caviar on toast; malt preparations. 

Full diet with certain restrictions embraces soft and liquid diet plus 
boiled fish, beef, mutton, and lamb stews, pot roast, broiled chicken, 
turkey, squab, venison, partridge, quail, tongue, hash, pickles (salt), corned 
beef, cauliflower, beets, asparagus, celery, potato salad, potatoes boiled 
in "jackets " and creamed, salt sardelles, anchovies, soused mackerel, 
creamed codfish, omelette, salmon, herring and herring salad, fillet of beef, 
cold meats, beefsteak, veal cutlets, capon, meat balls, meat dumplings 
with sardelle dressing, cheese (Roquefort, cream, imperial, Camembert); 
sandwiches: celery, lettuce, water cress, chicken, scraped beef, club, 
raw Westphalian ham, caviar, salt sardelles, with special restrictions when 
called for. 

Fever Diet for Adults and Older Children. — Beef broth and egg, mutton 
broth and egg, sago, eggnog, white of egg in water, soups, gruels, milk, 
malted milk, matzoon, kumyss, cocoa, tropon in peppermint tea, ice cream, 
water ices, custard, orange and pineapple juice, beef jelly, ginger ale. 

To these may be added in the convalescent stage : Apple sauce, baked 
apple, sponge cake, biscuits, rice, farina, bread pudding, cereals, scraped 
meat, scrambled eggs, or calves' foot jelly. 

Alcohol in the shape of whiskey, champagne, or Tokay wine is some- 
times of great value as a food and stimulant. Other articles may be selected 
from the list of liquid and soft diet. 

Fever diet for breast and bottle babies is discussed in the chapter on 
General Therapeutics and in that on Paediatrics. 

Stimulants and Beverages 

Alcoholic Drinks. — Alcohol as a beverage is unnecessary in young and 
healthy individuals. Persons in danger of the alcohol habit by inheritance 
should shun it. The abuse of alcoholic stimulation is invariably injurious. 
The temporary use of alcohol in certain diseases, in septic fevers in adults 
and in children, is of value and may become necessary to prolong life in 
connection with other stimulants. Given under the proper conditions 
and in proper amount, alcohol is capable of stimulating respiration, cir- 
culation, and digestion, and to a certain degree also of serving the purposes 
of a food and of supplying a certain amount of heat. It is particularly 
useful in senile loss of appetite. 

Malt Liquors. — Nutritious non-alcoholic malt liquors are obtainable 
under various names in the shops. 



STIMULANTS AND BEVERAGES 



237 



Beer contains bitter extract, sugar, and from 3 to 8 per cent of 
alcohol. 

Ale, porter, and barley wine contain from 3 to 7 per cent of alco- 
hol. Beer, ale, and porter are sometimes useful in insomnia. 

Wines. — White, Rhine, and Moselle contain from 9 to 12 per cent of 
alcohol. Convalescents may require a glass of light wine with a meal. 

Red wines contain from 9 to 10 per cent of alcohol and | per cent 
of tannin. Wines contain sugar, alcohol, and organic acids. French, 
Hungarian, and Rhine or Moselle wines may be taken after a meal in ano- 
rexia. Excellent American wines are now obtainable for half the price of 
the imported. 

Heavy Wines. — Sherry, Port, Madeira, Tokay, and Malaga are sweet 
wines. 

Aromatic Wines. — Bordeaux, Burgundy. 

Sparkling, or champagnes, contain from 12 to 14 per cent of alcohol. 
They are serviceable in prostration and collapse with vomiting. 

Non-alcoholic Drinks. — Tea, green and black, coffee. Stimulating to the 
nervous system. If tea and coffee produce nervousness, substitute cereal 
coffee, postum coffee, malt coffee. Cocoa, chocolate, kola cocoa (digestible 
cocoa is slightly stimulating and decidedly nutritious). Pure water, lemon- 
ade made with lime juice or lemon juice, ginger ale, peppermint tea, 
toast water, soda water will quench thirst. Hot water will often quench 
thirst better than ice water. Sucking a prune will also quench thirst. Milk 
is a drink and a food at the same time, and, on account of its impor- 
tance, will be discussed in a separate chapter (Facts about Milk). 

Mineral Waters. — Mineral waters may be divided into six principal 
groups: 

1. Still and Sparkling Alkaline Waters. — Vichy, Rhenser, Apol- 
linaris, Salzbrunn, Vals, Ems, Neuenahr, Fachingen, etc. Indications : 
Gout, acid dyspepsia, chronic gastrointestinal catarrh, gravel, cystitis, 
hepatic congestion. 

2. Sulphur Waters, Cold and Hot. — Baden in Switzerland; Aix les 
Bains, St. Honore, France; Neuendorf, Weilbach, Germany; Harrowgate, 
England; White Sulphur Springs, Ohio; Richfield Springs, Sharon Springs, 
New York; White and Red Sulphur Springs, Virginia; Banft, Canada; Glen- 
wood Springs, Colorado. Indications : Chronic articular, cutaneous, respir- 
atory, and gouty ailments. 

3. Saline Waters. — Saratoga waters, New York; Middlewich, Leam- 
ington, Cheltenham, England; Kissingen, Homburg (cold and warm), Pyr- 
mont, Kreuznach, Wiesbaden, Baden Baden (hot salt), Reichenhall, 
Nauheim (gaseous salt), Germany. Indications : Gastric, circulatory, and 
respiratory disturbances. 

4. Indifferent Waters. — Wildbad, Gastein, Ragatz; Schlangenbad, 
Badenweiler. 

5. Chalybeate Waters. — Schwalbach, Spa, Saratoga. Indications : 
Anaemic conditions. 

6. Laxative Waters. — Carlsbad, Marienbad, Tarasp, Saratoga laxative 
waters. Indications : Hepatic and gastrointestinal disorders, obesity. 

They are valuable in a measure in the management of divers troubles, 



238 



THE DIGESTIVE SYSTEM 



but the wonderful cures which they are supposed to effect are due to a 
combination of diet, exercise, and freedom from business and other worry, 
particularly in those instances in which the sufferer or alleged sufferer goes 
abroad and distance lends enchantment to the scene. 

Predigested Food 

Pancreatized food is sometimes serviceable when the digestive power is 
feeble, but is frequently ordered unnecessarily and in cases in which it is 
harmful. It is prepared by means of pepsin and hydrochloric acid or with 
extract of pancreas. The extract of pancreas is prepared by macerating 
for one week the pancreas of a pig, calf, or sheep with four times its weight 
of 50 per cent alcohol, and filtering. Peptonized food does not keep well 
and must be prepared several times a day. Beef or sarcopeptones are 
obtainable in the shops in a liquid or semisolid form, and can be made 
fresh by treatment of beef with the above mentioned extract of pancreas. 

Peptonized beef tea is made by adding ten grains of bicarbonate of 
sodium to a pound of lean beef and one pint of water. Allow to simmer 
for an hour. Mash the undissolved meat to a pulp, add a teaspoonful of 
extract of pancreas to the beef tea and pulp, and keep warm for two hours. 
Then boil for three minutes, strain, and season with salt or celery salt. 

Pancreatized milk is readily prepared by means of peptogenic powder, 
which is obtainable in the shops (see Facts about Milk). It comes in glass 
tubes with full directions on each. It may be given to children in malnu- 
trition and feebleness of digestion during acute and subacute illness, but is 
only a temporary makeshift, as its prolonged use will result in a putrid 
condition of the gastroenteric tract. 

Concentrated Foods 

In malnutrition and feeble digestion the administration of concen- 
trated food may be necessary. 

Bee} meal is said to contain 77 per cent of proteids and 13 per cent of 
fat. It is tasteless and odorless. 

Soluble beef jelly is said to contain 50 per cent of proteids. It has a 
pleasant taste and odor, is nutritious, and may be added to consomme, 
broth, and gruel. 

Soluble beef and vigoral are said to contain from 50 to 60 per cent of 
proteids. They are very nutritious and palatable. 

Extract of beef, meat juice, and beef tea have little food value, but are 
slightly stimulating. A raw egg beaten up with beef tea will greatly enhance 
its value. 

Tropon, somatose, and plasmon are concentrated vegetable proteids. 
Tropon is not soluble in water, but can be taken in soup, tea, cocoa, or 
mush, also combined with iron (iron tropon). Somatose is soluble in water 
and can be used for nutrient enemas in wasting disease, etc. Condensed 
milk and evaporated cream rightly belong to the class of concentrated foods, 
but are discussed in the chapter on Milk. 



SYSTEMS OF DIET 



239 



Syste?ns of Diet 



Banting and Ebstein Systems. — These systems of diet may be com- 
pared as follows: 





Proteids. 


Fat. 


Carbo- 
hydrates. 


Total in 
24 hrs. 


Calories. 


Banting 


Grammes, 171 
" 102 


8 
85 


75 
47 


254 
234 


] ,085 
1,400 



In the Banting system starch, sugar, and fluids are forbidden. The 
bulk is made up by fruit and vegetables. In the Ebstein system fat is 
illowed, and this diminishes the appetite and craving for food. Sugar and 
starch are forbidden except three and a half ounces. Fluids are restricted. 

Breakfast. — Cup of tea without sugar or milk, bread or toast with 
iwo oz. of butter. 

Dinner. — Soup, 4 to 6 oz. of meat, vegetables, salad, fruit, and black tea. 
Supper. — Tea, egg, fish, ham, cold meat, buttered toast, fruit. 
Oertel and Schwenninger System : 





Proteids. 


Fat. 


Carbo- 
hydrates. 


> it It It 


150 

250 


50 
25 


200 
100 



md withhold fluids. No fluids at meals. Climbing of graded paths, mas- 
sage, baths. 

In the foregoing table No. 1 is for cases where there is fat accumulation 
without much respiratory and circulatory disturbance; and No. 2 where 
ihere is fat accumulation with respiratory and circulatory disturbance. 

The caloric value of twenty-four hours' food in Banting's system is 
ibout 1,100; in Ebstein's, about 1,400; in Oertel and Schwenninger's, about 
J,000. 

Weir Mitchell System. — Rest, passive exercise, massage twice a day, 
md Swedish movements. Skim milk diet, gradually introduced until 
jatient lives entirely on milk. Vary the monotony with beef, chicken, 
md oyster soup. In six weeks' time fat is reduced. 

Diet for Leanness. — First ascertain the cause. Give sugars and starch. 
Freedom from mental strain. Abundant sleep and rest. 

Diet for Obesity. — In a diet for obesity it is practically unimportant what 
s given, so long as the nutritive value is calculated. From a study of the 
'ood values as shown in the preceding pages, the actual value of the various 
iiet systems will readily be understood ; and this will enable the practitioner 
:o intelligently regulate the diet of any individual case in which he may be 
.nterested. 



240 



THE DIGESTIVE SYSTEM 



VEGETARIANISM 

From a study of the following menu 1 it will be seen that the dietary is 
made up of a proper variety of proteids, carbohydrates, and fats, and is 
calculated to exert a favorable influence on overfed individuals. The 
beneficial effects of vegetarianism do not depend upon the fact of its fol- 
lowers not taking animal food, but on their giving up former bad habits. 

A VEGETARIAN MENU 



DINNER 
Soups 

Cream of Peas Fruit 
Entrees 
Broiled Nuttolene — Tomato Sauce 
Sliced Savory Protoso 

Nut Roast with Potatoes 

Relishes and Salads 
Celery Apple and Banana 
Vegetables 
Sliced Tomatoes Stewed Navy Beans 
Green Corn Potatoes 

Dextrinized Grains 
Toasted Whole-wheat Wafers 
Granose Flakes Granola Porridge 

Granut Zwieback Roasted Rice 

Browned Granose Biscuits 
Granola Dry Gluten 

Toasted Wheat Flakes 

Cereals 
Farinose — Grape Sauce 

Granola Porridge — Raisins 

Liquid Foods and Beverages 
Vegetable Broth Caramel-Cereal 
Gluten Gruel Grape Gruel Dairy Cream 
Sterilized Dairy Milk Almond Cream 

Fermented Breads 
Coarse Graham Bread Fine Graham Bread 
White Bread 



Unfermented Breads 
Beaten Biscuits 
Graham Crackers Passover Bread 

Crisps 

Cooked Fruits 
Prunes Peaches Strawberries 

Fresh Fruits 
Plums Peaches Cantaloupe 

Desserts 

Shelled Walnuts Bread Pudding 



ARTICLES SERVED TO ORDER 

Carbon Crackers Gluten Biscuit No. 1 

Gluten Wafers Dyspeptic Wafers 
Popped Corn 
Vegetable Bouillon 
Junket Buttermilk Kumyss Kumyzoon 
Milk with Lime Water 
Tomato Sauce Stewed Tomatoes 
Corn Pulp Granose Balls Protose Patties 
Floated Eggs Eggnog 
Green Peas Bean Pur6e Pease Puree 
Milk Custard Prune Marmalade 

Malted Foods 
Malt Honey Maltol Malted Nuts 

Sanitas Food Bromose 



EXERCISE AND DIGESTION 

Children's digestion suffers but little by active romping after a meal. 
Adults do not respond favorably to violent exercise after eating. Muscular 
fatigue and overexertion immediately before eating are not desirable. 
Dyspeptics should lie down for half an hour before eating. Aged people 
can take a short rest of half an hour after dinner. After eating a heavy 
meal, one should wait two hours before going to bed. 

Hunger produces wakefulness. Take crackers, beer, milk, and toddy. 



1 Battle Creek Sanitarium. 



TOBACCO, FOOD AND DIGESTION 



241 



In old age the circulatory and nervous systems are less active, the 
digestive power is less vigorous, and there is not so much demand for fuel 
in the body. Diminish the total quantity of food, give food in small 
amounts at frequent intervals, give easily digestible food, and live moderately 
and thereby prolong life. 

TOBACCO, FOOD, AND DIGESTION 

No definite rules can be formulated for the use of tobacco in relation 
to meals. Persons who are not made nervous or irritable by smoking after 
eating may do so if they enjoy it. Mild tobacco favors peristalsis and 
sometimes overcomes fatigue. Smoking before meals often destroys the 
appetite and interferes with digestion. Tobacco in its relation to diseased 
conditions will be discussed under various headings. 

Rectal alimentation and feeding by tube are discussed in the chapter on 
General Therapeutics. 



CHAPTER V 



THE DIGESTIVE SYSTEM — Continued 

DISEASES OF THE MOUTH 

Synopsis: General Remarks. — Slobbering. — Dryness of Mouth. — Gingivitis. — Bleeding 
and Spongy Gums. — Stomatitis (all forms). — Noma. — Urticaria of Mouth. — Actino- 
mycosis. — Foul Tongue and Breath. — Glossitis. — Benign and Malignant Ulceration of 
Tongue. — Herpes of the Tongue. — Swollen Papilla*. — Cyst and Concrements. — Ranula. 
— Herpes. — Eczema. — Fissures of the Lips. — Care of the Teeth. — Emergency Treat- 
ment of Toothache. 

GENERAL REMARKS 

A clean mouth is one of the best prophylactics against disease, and is 
consequently of very great importance to the individual. The mouth is 
not only frequently the seat of purely local disease, but is prominently a 
favorable portal of entrance for microbial and putrid products which are 
known to be factors in the production of most profound constitutional 
disturbances. 

It will readily be understood that in persons afflicted with chronic 
ailments in most instances the mucous membranes have lost their integrity 
in consequence of malnutrition, and consequently offer but slight resistance 
to microbial invasion. Thus are explained the many and often fatal com- 
plications arising in the course of subacute and chronic disease. In the 
course of acute infectious fevers less saliva is secreted, the mouth becomes 
dry and hot, and in this manner local infection and invasion are favored. 
Patients suffering from stomatitis or putrid mouth swallow much septic 
material and readily infect the gastroenteric tract. Certain forms of sto- 
matitis should be looked upon as eliminative phenomena 1 in which the 
bacterial character of the lesions plays a secondary role, in which local 
treatment of the mucous membrane must be combined with the best 
hygienic management in order to get satisfactory results. As a prophy- 
lactic measure, kissing of children on the mouth must be forbidden, as 
this habit obviously enough is a prolific means of disseminating infectious 
and contagious disease. Carious teeth must be extracted or filled. In the 
case of children with temporary teeth a cement filling may be inserted. 
Children and grown persons should seek to live in the best possible hygienic 
surroundings and sleep in cool rooms with windows open, encouraging con- 
stant ventilation. Sunshine, fresh air, and plain, nourishing food are the 

1 Elimination as an ^Etiological Factor of Diseases of the Alimentary Canal. By Dr. 
F. Forchheimer, of Cincinnati (Transactions o} the American Pwd. Soc, 1896). 
242 



BLEEDING GUMS, STOMATITIS 



243 



best medicaments, regarded from the standpoint of prophylaxis, and mouth 
washes and gargles are of great value. 

Regarding the classification of disorders of the mouth it may be stated 
that attempts have been made at nomenclature based on the microbes 
found in various inflammatory diseases of the mouth. For practical pur- 
poses, we may consider in this chapter the clinical forms met with in prac- 
tice, from the simple inflammatory type to those of more severe and destruc- 
tive nature. For diseases peculiar to infancy and childhood, see Paediatrics. 

DISEASES OF THE MOUTH 

Slobbering. — This manifestation, which is aptly enough described by 
the name accorded it, is not of infrequent occurrence in early infancy and 
during the period of dentition. Though frequently ascribed to local irrita- 
tion, difficult dentition, and uncleanliness, it is not necessarily so caused; 
and presents no special pathological features. In adults it is often associ- 
ated with other depraved habits, also in idiots, epileptics, and those morally 
and physically degenerate. 

Dryness of the Mouth ; Arrest of Salivary and Buccal Secretion (Xero- 
stomia). — This condition is often annoying and of sufficient clinical signifi- 
cance to call for treatment. Glycerin and rose water, equal parts, used as 
a mouth wash, will alleviate the trouble. When it occurs in febrile disease 
and in mumps water should be copiously administered. 

Gingivitis. — This acute inflammatory condition of the gums is occasioned 
by the presence of decayed teeth, retained, decomposing secretions, or local 
infection. In impaired general health and lowered vitality the gums are 
quite apt to take on this inflammatory disorder. The gums are painful 
and injected and bleed readily, and the treatment must be directed to re- 
moving the local cause (e. g., decayed teeth must be filled or extracted). 
Astringent mouth washes will accomplish much to allay and cure the affec- 
tion. Tincture of myrrh and tincture of rhatany, equal parts, applied with 
a cotton pledget along the affected gum area, are very efficacious. Tannate 
of glycerin in water as a mouth wash, and chlorate of potassium administered 
internally and used as a wash, are most efficacious remedies. Permanganate 
of potassium in water (rose colored solution), used frequently as a gargle, 
will accomplish much in the way of cleansing the mouth of decomposing 
material by its oxidizing power. 

Bleeding of the Gums, Spongy Gums, Discoloration of the Gums. — In- 
dependent of the acute inflammatory affections of the gums, bleeding is 
observed in persons of feeble health and as a prominent symptom of 
scurvy, the slightest touch frequently being sufficient to provoke bleeding. 
When the bleeding does not respond to the simple methods, prolonged 
pressure over the part with pledgets of cotton saturated with alum solution 
or persulphate of iron may favor cessation of the bleeding. Antipyrin in 
10 per cent watery solution, applied locally, also has haemostatic proper- 
ties and may be of service. Suprarenal preparations in solution will in 
many instances prove very efficacious. Means adapted to the improve- 
ment of the general health must be employed in addition. When the 
sponginess and bleeding may be attributed to the abuse or prolonged use 
of mercurials (red line gums) and lead preparations (plumbism, blue line 



244 



THE DIGESTIVE SYSTEM 



gums) , the administration of these drugs must pro tempore be discontinued. 
The treatment of hsemorrhagic gums in scurvy is described under Scurvy. 

Stomatitis Catarrhalis (Simple or Erythematous). — This form of inflam- 
mation is usually of mild type, runs an acute course, terminating in about 
a week, and is associated with no pronounced constitutional disturbances. 
It is generally observed during infancy and is caused by the introduction of 
irritating and unclean substances into the mouth (e. g., dirty fingers, unclean 
nipples). It may be concomitant with or secondary to the exanthemata 
and gastrointestinal affections. 

The symptoms are mild; there is some rise in temperature, and the mouth 
at first is red, dry, and hot. Thirst, pain, and irritability are present; 
later the mouth becomes moist and there is increased salivation. The 
changes in the mucous membrane consist simply of local hypersemia, in- 
creased epithelial proliferation, and subsequent desquamation with little 
or no tendency to ulceration. 

The treatment of this affection consists in keeping the mouth clean. 
Care is to be taken that the nipples and fingers are rendered clean before 
being introduced into the mouth. The mouth may be cleansed with 
sterile water or mild boric acid solution (2 per cent) or a mild solution of 
borax in water and glycerine. Should constipation exist, a mild laxative 
may be exhibited. 

Stomatitis Follicularis (Aphthous or Vesicular Form). — This is of severer 
type and longer duration than the simple catarrhal form. The local tissue 
changes are more marked and the constitutional disturbance more pro- 
nounced. Causative agents are any of the severer constitutional diseases, 
a deteriorated state of health, malnutrition, and unhygienic conditions and 
surroundings. The changes observed in the mucous membrane consist 
in the appearance of vesicles which ulcerate and have shallow, well defined 
grayish yellow denuded surfaces which later heal. The affection is in many 
instances so painful that the child refuses nourishment. 

Treatment. — A pale rose colored solution of permanganate of potassium 
is an efficacious mouth wash. It is best applied by swabbing the mouth 
frequently with cotton pledgets moistened with the solution. Boric acid, 
six parts, salicylic acid, one part, water, five hundred parts, make an 
excellent wash. Among other agents which may be employed are alum 
water (a teaspoonful to half a pint) or tannic acid (one drachm, glycerine, 
one ounce), thirty drops to a wineglassful of water, also Labarraque's 
solution, in water of the strength of one in twenty. 

Stomatitis Ulcerosa. — In this form destructive tissue changes are still 
more marked than in the foregoing affections. Tissues adjacent to the 
ulcerated areas are hard and infiltrated. The gums are chiefly the seat of 
the ulcerating process, and there is much puffiness and swelling and bleeding 
of the affected gums. There is, moreover, a decided foetid odor from the 
mouth. Besides local infection or putrid decomposition, scorbutus, saliva- 
tion induced by mercury (ptyalism), and malnutrition are causative agents. 
Children suffering from ulcerative stomatitis are decidedly sick, particularly 
the debilitated and cachectic from prolonged illness. In protracted cases, 
too, glandular swelling follows the local absorption of decomposed material 
and frequently terminates in suppuration. 



CANCRUM ORIS 



245 



Treatment. — Fresh air, nutritious food, and attention to hygiene 
are important essentials. Constitutional diseases acting as causative factors 
will call for treatment. For local use, a 2 per cent solution of potassium 
chlorate in a wineglassful of water, to which thirty drops of tincture of myrrh 
and thirty drops of compound spirit of lavender may be added, will be found 
beneficial. Dilute hydrochloric acid, gtt. 2 to 5 in sugar water, may be 
administered internally to aid digestion. Two per cent boric acid solution, 
to one pint of which may be added thirty drops each of formalin and 
spirit of wintergreen, is a useful mouth wash. Weak solutions of peroxide 
of hydrogen or alum, a teaspoonful to half a pint of water, are also ser- 
viceable. 

For bleeding gams a saturated alum solution, suprarenal capsule solution, 
or 10 per cent antipyrine solution, locally applied, will frequently prove 
very effective and has given satisfactory results even in the case of bleeders. 
Still, instances will occur where one will be compelled to resort to the actual 
cautery (Paquelin) to check the bleeding. There are also graver cases. 
For example, in diabetes, nephritis, and chronic hepatitis with jaundice, 
patients may bleed from the gums for days; and moribund patients may 
bleed even up to the time of death, notwithstanding the best of attention 
and efforts to check the bleeding. 

Stomatitis Gangrasnosa (Noma, Cancrum Oris), is of rare occurrence 
and is characterized by a rapid gangrenous destruction of tissue involving 
the neighboring structures of the mouth. It is probably of microbic origin. 
Debilitating disease and bad hygienic conditions presumably act as pre- 
disposing factors. The affection is at first local, appearing as a small 
inflamed spot, rapidly becoming gangrenous, spreading, and involving 
the surrounding tissue. This destructive process, if left unchecked, attacks 
the bony structures in its vicinity, involving the cheek and whole side 
of the face. It is unlimited in its destructive progress, and unless it is 
checked sufficiently early, death ensues as a result of general sepsis, the 
lungs, heart, liver, and kidneys showing post mortem evidences of profound 
degenerative changes. 

The indications for treatment are to check, if possible, the advance of 
the destructive process, to prevent absorption and general systemic infection, 
and, further, to maintain the strength of the patient. Locally, antiseptic 
solutions are to be frequently and diligently employed. The actual cautery 
and strong escharotics must be used to remove sloughs and destroy the 
virulent process at its seat. When, however, the sloughing area is extensive, 
a radical resort to the knife is preferable, and the resulting deformity may 
later be corrected to a degree by a plastic operation. To sustain nutrition, 
the patient should receive strengthening food stuffs, beef broth, milk, eggs, 
farina, and rice; and, in addition, some tonic may be administered. Severe 
cases of noma have been favorably influenced by diphtheria antitoxine. 

Complicating pneumonia, gastrointestinal catarrh, nephritis, or sepsis 
will require special treatment directed to minimize the intensity of the 
poisonous invasion and to support general nutrition. Kissjel's treatment 
of noma is said to give excellent results. This procedure consists of the 
following steps: The gangrenous tissues are completely removed; the affected 
surface is scraped with a sharp spoon and washed with hot solution of boric 



246 



THE DIGESTIVE SYSTEM 



acid or permanganate of potassium. The ulcer is then thoroughly rubbed 
with iodoform, and a dry dressing is applied. If all the gangrenous tissue 
cannot be removed at once, the ulcer is rubbed with iodoform and covered 
with small pieces of gauze soaked in a 1 to 1,000 solution of potassium 
permanganate. The scraping is repeated on the following day, and the 
procedure is repeated until all the gangrenous tissue is removed. Then 
iodoform is rubbed into the ulcerated surface once or twice daily and the 
ulcer is washed with permanganate until it is closed by healthy granula- 
tions. Special attention is paid to the diet and to the disinfection of the 
air of the sick room. The children are forced to take nourishment by every 
possible means. 

Stomatitis Diphtheritica. — In the course of pertussis and measles not 
infrequently aphthous patches appear in the mouth and offer a suitable 
lodgement for diphtheria bacilli; the susceptible larynx may thus become 
invaded, and as a complication true diphtheritic croup may develop. Ob- 
viously instances of such complicating and serious disease forcibly impress 
us with the necessity of securing and maintaining thorough cleanliness 
of the mouth. 

Stomatitis Tuberculosa. — In the course of general tuberculosis occasion- 
ally small ulcerative patches appear in the buccal mucous membrane. The 
tendency of the ulceration is to progress. Microscopic examination of 
the scrapings for tubercle bacilli will assist in distinguishing this form of 
ulceration from the syphilitic or epitheliomatous form. Evidences of 
general tuberculosis will also aid in establishing the nature of the affection. 
The ulcerated areas may be cocainized and attacked with a curette, lactic 
acid, trichloracetic acid, chromic acid, or the actual cautery. 

Stomatitis Syphilitica. — As one of the many manifestations of syphilis, 
small patches (leukoplakia) simulating the exudates in follicular or aphthous 
tonsillitis and those occasioned by mercury are observed. The diagnosis 
is arrived at by obtaining evidence of a specific history and noting the other 
evidences (glandular enlargements, dermatitis specifica) of luetic infection. 
The affection promptly responds to antisyphilitic treatment. Mild cauteri- 
zation with nitrate of silver, gargling with chlorate of potassium solution, 
and a mouth wash of permanganate of potassium solution are valuable 
aids in the treatment. 

Stomatitis Gonorrhoica. — Though of very rare occurrence, still this affec- 
tion is met with in practice, and is characterized by the appearance of 
yellowish white patches on the tongue and hard palate. The diagnosis 
is established by microscopical examination of the exudate for gonococci. 
As associated evidences of this affection, gonorrhoeal vulvitis and ophthalmia 
may be present. The affection runs a mild, uncomplicated course, and boric 
acid solution and permanganate of potassium solution for mouth cleansing 
purpose are efficacious. 

Croupous (Membranous) Stomatitis. — Abrasions, wounds, and inflam- 
matory lesions in the mouth are frequently found to be covered with a yellow 
pseudomembrane which may be diphtheritic or non-diphtheritic. This 
occurs frequently as a complication of the eruptive fevers and whooping 
cough, and following operations on the mouth and tonsils. From the 
mouth it may spread to the nasopharynx and larynx. When it invades 



ULCER OF TONGUE 



247 



the latter, it may manifest itself as membranous croup. The significance 
of membranous stomatitis is underestimated in general practice. 

The treatment consists in washing and spraying with non-irritating 
mouth washes. Listerine, Seiler's tablets in solution, boroformalin, and 
the internal administration of from two to five drops of dilute hydrochloric 
acid in sugar water are to be recommended. A culture from the mouth 
will reveal the presence or absence of diphtheria bacilli. When they are 
present, 2,000 units of the diphtheria antitoxine should be injected in the 
usual way, in order to prevent further systemic infection. 

Urticaria of the lips, tongue, cheeks, gums, and throat and other mucous 
membrances is found in connection with skin urticaria and other angeio- 
neurotic manifestions. 

Actinomycosis of the Mouth. — The ray fungus, or Actinomyces, is the 
cause of this chronic inflammatory affection. The parasite is found in 
the pus in the shape of small yellowish granules, made up microscopically 
of threads radiating from a centre. The fungus is taken in with the food, 
but may be transmitted in other ways. The author has observed this 
disease in stable and laundry workers. When localized in the mouth, it 
first presents itself as a small granulation tumor. The surrounding con- 
nective tissue becomes infiltrated, and finally pus foci form in the indurated 
tissue. 

The treatment is by incision, curettage, cauterization, and excision, 
and the internal administration of potassium iodide. 

Leptothrix buccalis is occasionally observed. (See Leptothrix of the 
Tonsil.) 

Foul tongue is occasioned by the presence of retained secretions in the 
buccal cavity or local disease of the organ itself, and most frequently is 
due to the existence of digestive disorders or systemic disease. 

Tongue Swallowing. — Asphyxia from swallowing the tongue, owing to 
its riding over and shutting off the opening of the glottis, is occasionally 
observed. The tongue is drawn back and down over the glottis by the 
muscles of deglutition, and the condition is due to a congenitally long or 
large tongue or a lax frenum. It calls for immediate relief. The tip of 
the tongue may be caught up by the finger, forceps, or suture, and drawn 
toward the cheek or forward whenever the danger of asphyxiation threatens. 

Diffuse Glossitis. — This inflammation is most frequently occasioned by 
traumatism or the presence of carious teeth causing irritation, or it may 
be caused by irritants or poisons locally applied. It occasionally follows 
the use of iodine or mercury. There are swelling of the tongue, salivation, 
and some fever; the affection is painful, and frequently the tongue is so 
swollen that deglutition and even respiration become embarrassed. 

The treatment resolves itself into keeping the tongue clean, administer- 
ing cracked ice to allay the inflammation, and the use of fluid food. Should 
the swelling occasion alarm as to respiratory difficulty, free scarification 
should be resorted to on the dorsal surface of the organ. 

Simple Ulcer of the Tongue and Its Frenum ; Dental Ulceration ; Riga's 
Disease. — The presence of carious teeth in the mouth and prolonged friction 
of the tongue or frenum against the teeth are causes. The introduction 
of strong destructive irritants or poisons is also a factor in causing the ulcera- 



248 



THE DIGESTIVE SYSTEM 



tive process. As a rule, touching the base of the ulcer with a nitrate of 
silver stick suffices after a few applications to cure. Decayed teeth which 
have acted as factors are to be extracted or filled. In the adult, ulcer of 
the tongue occurs as a result of the incessant use of a pipe, e. g., in cases in 
which the pipe stem acts as an irritant. Should the ulcer not respond 
to simple treatment as described, or become infiltrated and indurated and 
extend, we may suspect syphilis or malignant disease, and accordingly 
treat by radical surgical interference or antisyphilitic therapy. 

Syphilitic Ulceration of the Tongue. — Superficial and deep ulcers occur- 
ring in the early and later stages of syphilis are frequently enough met. 
Induration, glandular enlargements, specific dermatitis, and other signs 
of syphilis serve to distinguish this form of ulceration from tuberculous or 
epitheliomatous ulceration. The microscope, too, is a most valuable aid 
in assisting in the differential diagnosis. Where the ulcer is superficial 
and not much destruction of tissue has taken place, frequent applications 
of a strong solution of permanganate of potassium will often induce healthy 
granulation. For deeper ulceration, cauterization with nitrate of silver, 
the actual cautery, and curettage are indicated. In painful ulceration 
applications of cocaine solution will afford relief. As accessory agents, 
mouth washes are to be liberally employed. Most important, however, 
is the institution of rigid constitutional treatment with large doses of iodide 
of potassium or the iodides combined with mercury. 

Tuberculous Ulceration of the Tongue. — This is not of frequent occur- 
rence, and is seen in cases in which general tuberculosis exists. There is 
nothing descriptively characteristic of the ulcerative process which may aid 
one to distinguish by the appearance, this type of ulceration from the syph- 
ilitic. There is not the associated glandular enlargement, as a rule, such as 
we find in the syphilitic form, nor is there much if any induration of the 
neighboring tissue. The tendency, as with the syphilitic or epitheliomatous 
variety, is to spread and progress. Instances are on record in which syph- 
ilitic ulcerations have been microscopically diagnosticated as tuberculous 
owing to the accidental presence of tubercle bacilli. Such ulcerations 
heal promptly under antisyphilitic treatment. Their association with the 
existing general tuberculous condition aids in arriving at a diagnosis. 

Treatment. — The treatment, locally, resolves itself chiefly into cleansing 
the ulcer and cauterizing it with nitrate of silver, and in some instances 
excision of the ulcer may be indicated. Constitutional treatment and the 
observance of the hygiene applying to general tuberculosis must of course 
be carried out. 

Epitheliomatous Ulceration of the Tongue; Cancer of the Tongue. — This 
form, to be absolutely distinguished from other forms of ulceration, requires 
the aid of the microscope. As a rule, it occurs about middle life, and as 
contributing causative agents local irritation (carious teeth giving rise to 
dental ulcer), old scar tissue, and possibly neglected frequent superficial 
ulcerative processes may be local factors in initiating the progress. These 
forms of ulcer are generally situated on the side of the tongue, in the 
bicuspid or molar region, and have a tendency to grow rapidly, spreading 
downward toward the floor of the mouth and back into the fauces. One 
characteristic, though not diagnostic, feature is the presence of severe pain 



RANULA 



249 



and much salivation. The submaxillary glands and those of the neck soon 
become indurated and enlarged. 

Treatment. — The treatment is strictly surgical, and extirpation of the 
ulcerated and surrounding area is to be resorted to when the case is seen 
early enough in its course. Where there is extension with associated glan- 
dular enlargement, extirpation of the organ is imperative, and a secondary 
operation for removal of the involved glands, submaxillary and cervical, 
is to be undertaken. Should the disease have reached such a stage that 
the case becomes unsuitable for an operation, resort must be had to palliative 
and supportive measures. Locally, frequent applications of cocaine and 
the use of morphine hypodermically will alleviate much of the patient's 
suffering and render the unfortunate state bearable. Exposure to the 
action of x rays, Finssen light, or radium salts may be tried. An operation 
should not be undertaken until after the patient has had the "benefit of 
the doubt " (i. e., by antisyphilitic treatment). 

Herpes of the tongue is occasionally met. It gives rise to considerable 
discomfort, but disappears spontaneously. An antiseptic mouth wash 
may be used. 

Swollen Papillae of the Tongue. — As a result of irritation, e.g., excessive 
or prolonged smoking, or sudden contact of the tongue with very hot or 
acid fluids, the papillae may become swollen. This condition is most fre- 
quently seen affecting the papillae near the posterior portion of the tongue, 
and it gives rise to a burning sensation in the throat. The swollen papilla? 
disappear spontaneously, or may be cauterized with 5 per cent nitrate 
of silver solution. If chronically enlarged, they may be snipped off with a 
pair of scissors. 

Lymphangeioma of tongue, or cysts, or hygroma, may require the actual 
cautery. Benign tumors should be extirpated. 

Salivary Concrements. — Deposits of the contained calcium phosphate 
or magnesium salts from salivary secretions are occasionally found in the 
crypts and folds and at the orifices of the muciparous follicles of the buccal 
cavity, and frequently appear spontaneously in the secretions from the 
mouth; or, where large and in view, may be expressed by means of a forceps 
or small spoon. 

Ranula. — This condition is the result of occlusion of one or several 
mucous ducts resulting in cystic formation, and it is most frequently seen 
on either side of the tongue in the floor of the mouth, protruding and pre- 
senting a shining, slightly bluish surface. In many instances profuse 
salivation is present, and where the cyst is rendered very tense by its fluid 
contents, pain is an additional symptom. 

The treatment is to incise and remove as liberal a piece of the sac as 
possible, and to avoid coaptation of the edges of the wound, and thus prevent 
adherence of edges of wound and refilling of the sac. In addition, the edges 
and cavity of the attacked area may be swabbed with a solution of nitrate 
of silver to encourage healing. 

Herpes of the Lips. — In the course of acute febrile diseases, such as colds, 
pneumonia, typhoid fever, measles, and scarlet fever, herpetic areas develop 
on the lips, slightly involving the cutaneous area. The vesicles are painful 
and have a tendency to dry in from a few days to a week. As a rule there 



250 



THE DIGESTIVE SYSTEM 



is no spontaneous rupture, and in the treatment the object is to encourage 
drying of the vesicle, so that the resulting crusts may become less a source 
of irritation than where attempts at rupture have been instituted. Camphor 
ice acts admirably as a soothing application. 

Perlesche usually starts as a small crack, or fissure, at the angle of the 
mouth, and in consequence of irritation, licking with the tongue, and sub- 
sequent addition of infectious material, it spreads in breadth and depth, 
assuming an ulcerous character, and is covered with a grayish exudate. 

The treatment consists in cleansing the site and touching the fissure 
or ulcer area with nitrate of silver and protecting with a soothing ointment 
(camphor ice). 

Eczema of the Lips. — This frequent affection attacks the border of the 
lips, involving the median portion and spreading toward the angle of the 
mouth. Many minute cracks and fissures are present, and the painful 
surface bleeds readily. Local applications of mild ointments, such as boric 
acid with vaseline (10 per cent), or mild zinc oxide ointment with lanolin, 
will assist in hastening the healing process. 

Cracks and Fissures of the Lips. — Local irritation, exposure to cold, 
and contact of the lips with acrid substances are exciting causes of this 
condition, which simulates eczema of the lips very much. Camphor ice 
applied diligently will remedy the condition, and where the fissures become 
deep, touching with nitrate of silver stick after stretching the lips will suffice 
to cure. 

Foul Breath. — Independently of acute or chronic digestive disorders 
or diseases, we frequently observe a foul breath as an evidence of retained 
secretions behind the plica tonsillaris, also as the result of dental caries, 
nasal catarrh, and oesophageal and respiratory diseases. To combat the 
symptom, independently of the causative factors, antiseptic gargles are 
indicated. Where the causative factors can be attacked mechanically, 
they should be removed. Footor ex ore is rarely due to chemical changes 
in the salivary secretion. 

Sordes. — In febrile and debilitating disease the lips are frequently 
coated with a brown mixture of food remnants, epithelial debris, and micro- 
organisms, for which frequent washing and the application of camphor ice 
are indicated. 

THE CARE OF THE TEETH 

By William Caille, D.D.S. 

The value of a good set of teeth is not to be computed, if only the service 
of dividing and masticating the food is considered, mastication being the 
first step in a series of processes by which the food is transformed into 
nourishment adapted to the needs of the system. When to this considera- 
tion we add their importance in assisting vocalization — distinctness of utter- 
ance in speech and song — and also when we consider the intimate relation 
that exists between the innervation of the organ of hearing and the dental 
apparatus, it can easily be understood that any pathological condition 
in the one may cause symptoms referable to the other. As we know, the 
sensory innervation of the ear is derived from the fifth, or trigeminal, nerve; 



CARE AND TREATMENT OF THE TEMPORARY SET OF TEETH 251 



this nerve, through the superior and inferior maxillary branches, is the 
sensory nerve of the teeth. 

Thus dental caries is often the cause of severe reflex symptoms more 
or less remote — such as " otalgia " (pain in the ear) or a general neuralgia 
in the head. The patient is dosed with medicine for a long time without 
getting relief, and finally drifts into the hands of a dentist, who finds a 
badly decayed wisdom tooth to start with. After its extraction (if too 
far gone to fill) the pain in the ear vanishes. Treatment of all other teeth 
found to be carious finally results in a general feeling of comfort to the 
patient, with no recurrence of neuralgia. It is important to bear in mind 
at all times the possibility of reflex 



pain from an irritating tooth and also 
the intimate relation between dental 
caries and systemic diseases. 

The Care and Treatment of the 
Temporary Set of Teeth 

The temporary teeth contain a 
much larger amount of animal matter 
than the permanent, are consequently 
of a less dense structure, and, there- 
fore, are more liable to rapid decay. 




The pulps of the deciduous teeth are w w 
relatively larger than the pulps of FlG - 103 - 

the permanent teeth, and when nearly 

or quite exposed by decay are more susceptible to the action of irritating 
agents and are more apt to lose their vitality under untoward influence. 
They demand more care and attention for this reason than the permanent 
teeth, especially when we consider how very important it is to preserve the 
first set until their successors are ready to appear. 

At about the fifth month after birth the process known as the eruption 
of the teeth begins. The rule is that the lower teeth precede the upper 
of the same class by two or three months. They generally appear in pairs. 
The usual order of their eruption is as follows: 

Upper set — Two central incisors, between the fifth and eighth months. Two lateral 
incisors, between the seventh ani tenth months. Two canines, between the twelfth and 
sixteenth months. Two first molars, between the fourteenth and twentieth months. 
Two second molars, between the twentieth and thirty-sixth months. 

The lower set consists of the same number of teeth, known by the same 
names. It must not be forgotten that the eruption of the second set begins 
before any of the first teeth are shed. Thus, between the fifth and sixth 
years the first permanent molars, four in number, one on each side of the 
upper and lower jaw, make their appearance. These are generally sup- 
posed by parents to belong to the first set, and, therefore, if they are found 
decayed shortly after their eruption, no attention is paid to them, because 
it is thought they will soon have to make room for their successors, and 
before the error is discovered the mischief is irreparable. 



252 



THE DIGESTIVE SYSTEM 



For reasons not fully understood, a great liability exists in the sixth year 
molar to deep fissure formation, with imperfect union of the enamel edges, 
and from this and other causes we recognize a special tendency to caries; 

in fact, these teeth are fre- 
quently decayed before they 
are fully protruded. This fact 
shows the importance of extra 
care and more prompt atten- 
tion to them, for if they can be 
preserved until they become 
thoroughly solidified, their 
proneness to decay is very 
much lessened, and the chances 
of retaining them throughout 
life are correspondingly in- 
creased. The six year molars 
are the largest teeth in the 
mouth, consequently they are 
very important as masticators. 
The want of a proper appre- 
ciation and proper treatment 
Fig. 104.— At six years. of these six year molars is one 

of the most fruitful causes of 
the defective masticating apparatus of a vast majority of people at and 
beyond forty years of age. 

Shedding of the Temporary and Eruption of the Permanent Set 

When the small size and delicate structure of the jaws of an infant, 
and the fact that the teeth correspond to them in size, are considered, it 
will be apparent that the provision of a second set, large and strong in 
proportion to the increased size and strength of the adult jaw, is a necessity. 
Almost coincidently, therefore, with the development of the germ of each 
temporary tooth, and in what may be termed an appendage to the sac in 
which it is enclosed, appears the germ of its successor. While, therefore, 
the development of the temporary teeth is advancing, the germs of the 
second, or permanent, set are also progressing. When the former make 
their appearance the latter are in various stages of development. 

The second, or permanent, set of teeth are thirty-two in number, the 
sixth year molars constituting a part of this set. The following tables give 
the average time and order of eruption of the permanent teeth. 

First molar, between five and six years. Central incisors, between six and eight 
years. Lateral incisors, between seven and nine years. First bicuspids, between nine 
and ten years. Second bicuspids, between ten and eleven years. Canines, between 
eleven and thirteen years. Second molars, between twelve and fourteen years. Wisdom 
teeth, between seventeen and twenty-one years. 

The period included between the sixth and the fourteenth years of the child's 
life is an exceptionally important one with reference to the care of the teeth, 
their subsequent condition for life depending largely upon the treatment 




SHEDDING OF TEMPORARY AND ERUPTION OF PERMANENT SET 253 



during this period. This attention on the part of the parent or guardian 
should consist, not only in advising or directing the habitual thorough 
cleansing of the teeth of the child, but should include a personal supervision 
of the operation, in order that serious omissions as to time or manner may 
not occur. In addition, a systematic examination of the mouth by a com- 
petent dentist should be made at frequent intervals. Teeth become carious 
from constitutional as well as local causes. 

The difference between individuals in the physical character of the 
teeth (differences in their organization, ossification, and density, and con- 
sequently in their healthfulness, usefulness, and durability) are generally 
in harmony with other constitutional peculiarities. The size, shape, and 
structure of the teeth indicate also their liability to decay or their power 
of resistance to unfavorable conditions. The character and progress of 
decay vary also in the several temperaments not less than does the orig- 
inal structure — liability to decay — its character and progress being, how- 
ever, much modified by the state of the general health. Teeth poorly 
organized may, by reason of favorable systemic conditions and intelligent, 
persistent care, be made to out- 
last even those of vastly su- 
perior original structure, but 
which succumb to unfavorable 
constitutional conditions or 
neglect. The temporary inter- 
ruption of nutrition by acute 
infantile diseases, such as mea- 
sles, scarlet fever, rickets, etc., 
is generally recorded distinctly 
in the dental organs. 

Teeth regular in their posi- 
tions, of large size, of a rich 
yellowish-brown color, with 
dentin as dense as ivory, and 
enamel thickly and evenly de- 
posited, represent a vigorous, 
healthy constitution, whereas 
teeth that are opaque and FlG - 105.— At six years, 

chalky, with enamel only semi- 
crystallized, deficient in quantity, and irregularly deposited, and the dentin 
soft or friable, represent constitutional poverty. 

The teeth are a part, and an exquisitely organized part, of the animal 
economy. They must, therefore, be more or less influenced by the state 
of the general health. 

Moreover, morbid secretions of the mouth in deranged systemic con- 
ditions tend markedly to the production of caries. Irritation of the mucous 
membrane, such as is caused by an accumulation of tartar which has insinu- 
ated itself between the gums and the necks of the teeth, will provoke a 
mucous secretion decidedly acid, and, as a consequence, destructive to 
tooth structure, also derangements of the alimentary canal are generally 
accompanied by acidity of the saliva. 




254 



THE DIGESTIVE SYSTEM 



Faulty articulation of the teeth very often prevents a thorough mastica- 
tion of food, also in children having a mouthful of carious teeth causing 
acute pain while eating, and forcing them to bolt their food, which soon 
results in dyspeptic troubles, and a general acid condition of the digestive 
fluids, which are regurgitated from the stomach to the mouth, acting in 
this way directly upon the teeth. 

Many cases have come to my notice in which faulty articulation could 
be traced back to mouth breathing, due to nasal obstructions, and requiring 
years of regulating to bring about a normal position of the teeth. Thumb 
sucking may in time bring on protrusion of the upper jaw, with sub- 
sequent derangement of the 
teeth. The physician can 
greatly help toward prevent- 
ing such a condition, because 
he generally is in touch with 
the patient long before the 
dentist sees him. 

As soon as the child has 
its first set of teeth, a careful 
examination of the mouth 
should be made by a compe- 
tent dentist, and if any cavi- 
ties are found, they should be 
carefully treated, and gutta 
percha, cement, or amalgam 
fillings inserted. I mention 
these three kinds of fillings 
because they are easily ma- 
Fig. 106.— At eleven years. nipulated, and the child is 

not subjected to a long sit- 
ting. For filling children's teeth, I prefer a non-conductive material, such 
as gutta percha, on account of the supersensitive condition of the tem- 
porary set of teeth; this will necessitate seeing the child more often than 
if metal fillings were used, but it is better in the end. 

Three sittings annually are not too many at this period of the child's 
life, owing to the fact that deciduous teeth easily crumble and break away, 
and thereby lose the fillings. Parents should teach their children how to 
use a mouth wash and handle a tooth brush ; the child will never forget the 
importance of this in later years if it is instructed early in life. 

The importance of keeping the child's mouth thoroughly clean at all 
times cannot be emphasized sufficiently. The mouth and nasopharynx 
are the portal of entrance for many infectious diseases, and a filthy mouth 
favors infection. 

Cleaning the Teeth 

If the teeth are properly cleaned on arising, they are freed from glutinous 
products of bacterial origin, which have vegetated during sleep, and the 
food that is taken during the day is then not likely to adhere to them; 
what food does lodge in the interdental spaces may be dislodged by the 




REMARKS ON THE EMERGENCY TREATMENT OF TOOTHACHE 255 



toothpick or floss. Any particles which remain probably do no harm in 
the few hours before the bedtime cleansing, because the activities of the 
mouth during the day will hinder, if not entirely check, the growth of 
microorganisms. The bedtime cleansing will, as far as possible, remove 
fermentable matter from the mouth which has accumulated during the day. 
Brushing with a dentifrice may be supplemented with floss and an antiseptic 
and alkaline wash. 

Antiseptics for oral use should be alkaline in reaction, not merely neutral 
but distinctly alkaline. A perfect dental antiseptic, besides being alkaline, 
should not coagulate albumin. It should be a powerful non-irritating 
deodorant. 

Remarks on Pulpitis-periostitis, Alveolar Abscess, and Alveolar Pyorrhea 

In toothache from pulpitis decomposed food acts as an irritant on the 
exposed pulp and nerve. A filling carelessly inserted and producing pressure 
on the vital part of the tooth may also cause pulpitis and ultimately the 
death of the tooth. Supersensitive teeth, into which a metal filling is 
inserted without first taking the precaution to line the cavity with some 
non-conducting material, frequently give trouble, as do metal filled teeth, 
with cavities extending almost to the pulp. Patients so afflicted complain 
of soreness and tenderness while eating and drinking. Toothache from 
pulpitis and periostitis is the most common form. Local inflammation 
may sometimes be checked by local applications, such as a hot water bag, 
a hot poultice of tea leaves, capsicum plaster applied over the dry gums, 
or equal parts of tincture of iodine and tincture of aconite applied to the 
gums by means of a brush or swab. Care should be taken not to allow the 
mixture to flow back into the mouth. After periostitis is more marked, 
the tooth may often be saved by opening up the pulp chamber. Relief 
is immediate, and subsequently the devitalized nerve may be removed and 
a general antiseptic treatment and final filling will be indicated. Alveolar 
abscess is treated by free incision, and alveolar pyorrhoea is treated by 
removing the source of irritation and by the prolonged use of antiseptic 
and astringent mouth washes. 



The dentist is, of course, in the best position to intelligently manage 
a toothache, but for the benefit of those out of reach of a dentist the follow- 
ing advice is given: 

Clean and dry the cavity by means of absorbent cotton on a wooden 
toothpick, and insert a pledget of cotton saturated with the following 
preparation: 



Remarks on the Emergency Treatment of Toothache 



R- Orthoform, 

Phenol (crystallized) 

Camphor 

Chloral hydrate, . . . 



1^ parts; 
1^ parts; 
4 parts ; 
4 parts. 



M. 



256 



THE DIGESTIVE SYSTEM 



The cotton pledget must not be too large, allowing room for a second 
pledget of cotton saturated with sandarac varnish. In a few minutes the 
varnish solidifies and protects practically as a waterproof filling. This 
method is very effective when we have an exposed pulp to deal with. Validol 
camphorate can be used in the same manner with good results, and as the 
Validol does not injure the surrounding tissues, it is especially valuable 
and safe in the hands of the patient. 

Brief Remarks on the Regulation of the Teeth 

The time that is generally considered most favorable for correction is 
between the thirteenth and eighteenth years; however, the health and 
strength of the patient at the time of any proposed operation for irregularity 
is so important a consideration that it must not be disregarded. The in- 
dividual is passing from the stage of childhood into that of manhood or 
womanhood, and in this change, especially in the case of the female, the life 
forces are taxed to the utmost. At this time also the mental faculties are 
being severely strained by study, in consequence of which, if the physical 
culture of the individual is neglected, as it too often is, the nervous system 
becomes unduly exalted. To meet and partially compensate for these 
drains upon the system, it is most important that full nutrition be sustained. 
To do this with teeth that are sore or tender to the touch by reason of 
operative interference is impossible, and hence the system will be still further 
weakened by lack of nourishment if any severe operation is undertaken. 
It is, therefore, much better to postpone the operation until a time when 
the vital power can stand the strain. 

Family Type of Dental Deformity 

When any great deformity of the teeth and jaws, such as anterior pro- 
trusion of either jaw or a V-shaped arch, is shown to be hereditary, it is 
well to take into consideration the hereditary feature of the case before 
beginning any work for correction. Where the irregularity is known to 
have been acquired in the parent of the child, and thus to have been trans- 
mitted but once, the difficulties in the case are not so marked, because 
the type has scarcely been confirmed; but where it has been transmitted 
through two or more generations the impress is strong and difficult to 
overcome. In the latter case the correction of the deformity will not be 
more difficult than usual, but after correction the tendency of perverted 
nature to cause a return to the family type will be so strong as almost to 
baffle us in our attempts to preserve the advantage we have gained. 



CHAPTER VI 



THE DIGESTIVE SYSTEM — Continued 

DISEASES OF THE CESOPHAGUS 

Synopsis: Remarks. — Anomalies of the (Esophagus, Thrush, Oesophagitis, Ulcer, Cancel 
Stricture, Sacculation, Paralysis, Rupture, Foreign Bodies in the (Esophagus. 

INTRODUCTORY REMARKS 

Function of the (Esophagus. — The function of the oesophagus is to carry 
food by successive contractile efforts from the pharynx to the stomach. 
Food is probably carried down by the oesophagus to a point below the 
bifurcation of the trachea, from which point it is squirted into the stomach 
upon the relaxation of the cardia. This accounts for the delay of from six 
to ten seconds between the first and second swallowing sounds which are 
heard at the tip of the seventh costal cartilage on the left side. The action 
of the cesophagus is involuntary and it applies alike to both fluids and solids. 
The muscular tube is innervated by the pneumogastric nerves; hence 
diseases affecting these nerves affect the act of deglutition. 

Composition. — The wall of the tube is composed of three layers, a mus- 
cular, submucous, and mucous. The muscular coat consists of a layer of 
longitudinal and another of circular fibres. The submucous coat contains 
the mucous glands. The lining, or mucous, coat is made up of stratified 
epithelium, the superficial or innermost layer of which is squamous. The 
knowledge of this minute anatomy will explain the terminal effects of injuries 
to the tube, whether mild or severe, depending upon which coat has been 
injured. 

Position. — The position of the cesophagus is slightly to the left of the 
median plane down to the fifth dorsal vertebra, from which point it inclines 
more to the left, ending at the cardiac orifice of the stomach. This point 
lies opposite the tip of the seventh costal cartilage, 2.5 cm. to the left of 
the sternum and about 10 cm. posterior. Posteriorly the point of orienta- 
tion is the fifth dorsal spine, thence descending to the left of the ninth dorsal 
spine. 

ANOMALIES OF THE OZSOPHAGUS 

Congenital fistula due to the failure of growth in fcetal development 
between the second and third branchial arches. The opening is above and 
external to the sternoclavicular articulation. A fistulous opening com- 
municating with the trachea may exist. 

The cesophagus may be absent. 

18 257 



258 



THE DIGESTIVE SYSTEM 



Obliteration of the lumen, leaving a fibrous cord to indicate the continuity 
of structure. 

Stenosis of the oesophagus may be congenital and give little or no incon- 
venience until late in life. 

Dilatations of the lumen may be congenital or may accompany stenosis, 
being situated immediately above it. Sacculations, or diverticula, may be 
congenital or may be due to a weakened wall yielding before the pressure of 
swallowing. Such formations are usually at the commencement of the 
oesophagus. Sacculations may also be due to adhesions and tension from 
without, or to cicatricial contraction within. 

Thrush of the oesophagus often accompanies thrush in the mouth in 
infants and yields to the treatment directed against this condition. 

ACUTE INFLAMMATIONS OF THE (ESOPHAGUS 

Acute inflammations of the oesophagus may be due to or accompany: 

1. Acute fevers when severe as in diphtheria, pneumonia, typhoid, small- 
pox, and pyaemia. 2. Mechanical, chemical, or thermal traumatism, when 
bodies capable of inflicting such injury have been swallowed. 3. Cancerous 
inflammation involving neighboring tissues, but not having yet invaded 
the oesophagus itself. 4. Some unknown cause, hence appearing spontan- 
eously, as in sucklings, with or without ulceration. 

Symptoms. — Symptoms of inflammatory conditions are more or less 
alike and are: Pain on swallowing, especially acute. Sometimes constant 
dull pain beneath the sternum. Regurgitation may be present, if there 
is a foreign body in the oesophagus. The diagnosis of the exact condition 
will depend upon the history and examination. The use of a bougie or 
o?sophagoscope is contraindicated during the acute stage. 

Treatment. — The treatment of oesophagitis depends upon the severity 
of the condition. If it is mild or slight, no special treatment is required 
other than with soft foods or demulcent drinks. In severe cases resort to 
rectal enemata and give no food by the mouth until the acute symptoms 
have subsided. Demulcent drinks and ice by the mouth may be used to 
relieve pain. Cold may be applied externally to the neck or sternum. 
Analgetics may be a necessary addition when severe symptoms exist. 
After corrosives have been swallowed we expect cicatricial contractions 
or strictures to show themselves in from three to six months. Bougies 
should be passed before that time to prevent the narrowing of the lumen 
and the occurrence of such a complication. 

CHRONIC INFLAMMATIONS OF THE (ESOPHAGUS— ULCER AND CANCER 

Chronic inflammatory conditions of the oesophagus, with and without 
softening, may follow the acute conditions mentioned above. 

Ulcers. — Ulcers of the oesophagus may occur in cachectic conditions, 
diabetes, nephritis, hepatitis, or malignant disease, including tuberculosis. 
In chronic heart disease with disturbed portal circulation the veins of the 
lower portion of the oesophagus may be dilated, and the lining membrane 
be covered with mucus due to a chronic catarrh. If these veins ulcerate 
through, or rupture from any cause, the patient may have a severe 



ULCER, CANCER, STRICTURE, PARALYSIS, RUPTURE OF (ESOPHAGUS 259 



haemorrhage, or may bleed to death without giving evidence of the haem- 
orrhage. The blood in such cases may be swallowed and retained in the 
stomach and intestines, or there may be slight haemorrhage and vomiting 
of the blood, and it will be a difficult matter to decide whether it is an 
oesophageal or a gastric haemorrhage. Again, the blood may be swallowed 
and pass per rectum and this be the only evidence of the haemorrhage. 
The use of the asophagoscope is a help in such conditions, especially if there 
are old ulcers, but it must be used with the greatest care. 

Cancer. — Cancer of the oesophagus is usually of the epithelioma type 
and may or may not ulcerate early, due to the mechanical irritation of 
the food. 

If the growth causes much stenosis, we get a gradual dilatation of the 
tube above the tumor due to accumulation of food distending it. This food 
may later be swallowed, but is usually regurgitated. As the cancerous 
growth advances it in volves the neighboring organs and may thus per- 
forate into the trachea, pericardium, aorta, or pleura or even erode the 
vertebrae. 

Symptoms. — Cancer of the oesophagus is more frequent in men over fifty, 
and it is accompanied with progressive dysphagia, first for solids and then 
for liquids, and rapid emaciation. Regurgitation may occur early or late. 
Pain may be a constant feature or occur only after eating food. Enlarge- 
ment of the cervical glands may occur. Three conditions simulate malignant 
disease — senile dysphagia, nervous dysphagia, and an oesophageal pouch. 
Spasmodic stricture may be caused by dyspepsia. 

Diagnosis. — The diagnosis is made by the passage of the bougie and 
from the symptoms enumerated. 

Prognosis. — The prognosis is hopeless, and the usual mode of death is 
from asthenia or sudden perforation of some vital organ. 

Treatment. — The treatment is to relieve the suffering, resorting to 
morphine, codeine, and cocaine without hesitation. Analgetics dissolved 
or suspended in mucilage give relief. Gastrostomy is advisable, if done 
eaaly, before asthenia is too pronounced. The use of the x-ray or radium 
has not been successful, though one case can be vouched for by the author 
where the stricture has been relieved and life apparently prolonged after 
a course of x-ray exposures. Radium as a cancer cure has not given satis- 
factory results. In every case of malignant disease the patient should have 
the benefit of the doubt and receive antisyphilitic treatment. 

STRICTURE, PARALYSIS, RUPTURE, ETC. 
Stricture of the oesophagus may be: 

1. Congenital. 2. Due to cicatricial contraction following ulcers due 
to corrosives, syphilis, or typhoid. 3. A result of tumors, benign or malig- 
nant, in the wall, narrowing the lumen. 4. Caused by pressure from with- 
out, as of aneurysms, swollen lymph glands, enlarged thyreoid, pericardial 
effusion, and tumors not involving the wall itself. 

Diagnosis. — The diagnosis of the true condition will depend upon a 
close study of the history and physical signs. From the history we may 
learn of the occurrence or non-occurrence of any previous traumatism, 



2G0 



THE DIGESTIVE SYSTEM 



or inflammatory condition, with or without a general or constitutional 
disease. The rapidity of the increasing severity of the symptoms is an 
important point. 

Symptoms. — Concomitant symptoms in other organs should be noted 
especially. If regurgitation is present, the time of its occurrence with 
respect to the ingestion of food is a fair indication of the position of the 




Fig. 107.— Introducing Oesophageal Bougie. 



stricture. Regurgitation immediately after swallowing indicates a high 
position of the stricture, but, if it is delayed, a low position. The fact that 
the food is regurgitated, and not vomited, can be discovered by the odor, 
the absence of hydrochloric acid, and the unchanged condition. Ausculta- 
tion for a delayed second swallowing sound also helps. Then, lastly, we 
may try the passing of bougies, beginning with the largest size of the olive 
tipped. Gentleness in manipulating a bougie is imperative, because of 
ou,'r ignorance of the actual condition and the possibility of rupturing the 
oesophagus and puncturing an important viscus. 



FOREIGN BODIES IN THE (ESOPHAGUS 



261 



Spasm or spasmodic stricture may occur in hysteria, hypochondriasis, 
chorea, epilepsy, idiocy, or hydrophobia and after irritation by foreign 
bodies. It may be a very painful condition, especially if some sharp 
body has been swallowed, and persist for a day or so, or even continue for 
weeks. The actual damage may be very trivial, but the nervous spasm 
and sensation of pain will persist. 

The treatment of such a condition is that of the general consti- 
tution. Sometimes a cure may follow the passing of a bougie, especially in 
neurotic conditions, if done with demonstrative formality. The bougie may 
or may not be arrested at the site of the stricture. Organic stricture of 
a non-malignant character requires dilatation by means of flexible bougies 
or it must be overcome by surgical means. A low down lesion can be reached 
by opening the thorax under negative pressure. 

Paralysis of the (Esophagus 

Paratysis of the oesophagus is very rare and usually of central origin, 
as in bulbar paralysis. Following diphtheria, there may be a peripheral 
paralysis. 

Prognosis. — The prognosis in the first would be hopeless, while in the 
second it would be good, unless the paralysis extended and involved some 
vital organ. 

Rupture of the (Esophagus 

Rupture of the oesophagus from violence or in the course of cancerous 
softening has a fatal termination. 

Foreign Bodies in the (Esophagus 

Foreign bodies in the oesophagus can be located by means of the bougie 
and by the use of x rays. The use of the Rontgen ray in the diagnosis of 
foreign bodies in the oesophagus is of the greatest value only when those 
bodies are metallic, as we then obtain a definite outline of them and their 
location. If the body is of some other material, we must use the greatest 
care in forming an opinion of the importance of the shadows on the plate. 
In such cases it is best to make two or more plates at intervals of some days, 
and compare them carefully. Even with the most careful comparison the 
x ray is not a positive factor in such diagnosis. One case has been recently 
recorded of an eminent surgeon who depended upon the x ray for the 
diagnosis of the position of a tooth plate said to have been swallowed by 
a patient. It was apparently located at the cardia, but when gastrotomy 
was performed nothing was found. The next day the tooth plate was 
found in a crevice of the bed. 

Fish bones and other small foreign bodies can sometimes be extracted by 
means of the bristle probang; coins and tin whistles by the coin catcher. 
When a foreign body is located and cannot be removed by such means or 
cannot be pushed into the stomach, surgical methods of removal must be 
adopted. 



CHAPTER VE 



THE DIGESTIVE SYSTEM — Continued 

CLINICAL PATHOLOGY OF THE STOMACH AND INTESTINE 
AND DIAGNOSTIC TECHNIQUE 

Synopsis: Clinical Pathology of the Stomach, Motor Phenomena, Sensory Phenomena of 
the Stomach. — Secretory Phenomena of the Stomach. — Hydrochloric Acid in the 
Stomach, Digestive Ferments. — Diagnostic Technique. — Transillumination with Fluo- 
rescein. — Remarks on the Clinical Pathology of the Intestine. — Motor, Sensory and 
Secretory Phenomena of the Intestines. — Diagnostic Technique. — Examination of 
Faeces. — Conclusions. 

REMARKS ON THE CLINICAL PATHOLOGY OF THE STOMACH 

A healthy stomach mechanically and chemically prepares the food 
for the intestines, and very little absorption takes place in the stomach 
proper. The normal motor function of the stomach is fairly understood. 
The fundus has a peristaltic action with little interior tension; the pyloric 
antrum has a strong muscular action with high interior pressure. A 
sphincterlike arrangement closes this segment against the fundus and permits 
the gastric contents to flow through the relaxed sphincter at the pylorus 
into the intestine. A very slow transfer of contents may be followed by 
a dilatation of the stomach and an undue formation of gas and fatty acids. 

Motor Phenomena and Neuroses 

Regurgitation and Vomiting; Singultus. — The cardia of the stomach 
will open during the act of swallowing. 

Regurgitation and eructation of gases, air, and fluids may take place 
from the oesophagus or stomach. If they are from the latter, hydrochloric 
acid and fatty acids will give an acid taste in the mouth (pyrosis, water 
brash) . 

Vomiting is due to a complex muscular action of the stomach and 
diaphragm combined. The impulse takes its origin in the medulla, near 
the respiratory centre, and may be due to local brain irritation or to a reflex 
from the abdominal vagus nerve, and the salivary glands also participate 
in the act. We speak of nervous, paroxysmal, and reflex vomiting ; cerebral 
or toxic vomiting from alcohol, apomorphine, chloroform, ether, sewer gas, 
bacterial poisons, sepsis, and urajmia. Reflex vomiting, if cerebral, is 
usually projectile and unattended with nausea or pain. It may be a premon- 
itory symptom of apoplexy or associated with meningitis, hydrocephalus, 
brain concussion, etc. 
262 



SECRETORY PHENOMENA OF THE STOMACH 



263 



Spasms of the stomach, pylorus, or cardia are frequently observed, also 
peristaltic unrest and peristaltic atony. 

Dilatation of the Stomach. — A dilated stomach acts like a dilated heart 
— its cavity does not empty itself. Pyloric stenosis is accompanied by 
dilatation of the stomach and is often compensated by hypertrophy of 
the gastric muscularis with subsequent degeneration of the muscular 
elements. Anomalies of form and position favor such changes, and then 
we speak of motor insufficiency. 

A dilatation without pyloric stenosis is found in connection with super- 
secretion, hyperacidity, and neurasthenia. Atony of the stomach may be 
due to undue fermentation and may cause undue fermentation or putre- 
faction. 

Speaking generally, we may affirm that in atony without dilatation the 
stomach is empty if examined in the morning before breakfast. This 
denotes weak peristalsis. 

In atonic dilatation the stomach is not obstructed, but is unable to empty 
itself, and food is found in washing the stomach in the morning. 

In dilatation due to pyloric obstruction we speak of secondary dilatation 
as we find it in cancerous, fibrous, or cicatricial obstruction. The wash water 
will show food in all stages of putrefaction. 

Sensory Phenomena of the Stomach 

In health we feel the stomach when we are hungry or when we overload 
it, and a sick stomach will show the overloaded feeling after a small quantity 
of food has been taken. Actual pain in the stomach (gastralgia) is constant 
in ulcers and cancer from irritation of HC1 and organic acids. Clonic 
muscular contraction in the walls of the stomach and intestine also pro- 
duces pain. Neuralgia of the stomach is observed in stomach neurasthenics 
and in tabetic subjects. Many phenomena in various parts of the body 
are of gastric origin, such as epileptoid and tetanic seizures, vasomotor 
phenomena, parsesthesias, and neuralgias of various parts, also migraine, 
vertigo, cardiac irregularities, and asthmatic complaints. 

Disorders of the Appetite. — Anorexia is a simple loss of appetite often 
observed in old people, in nervous people, and in persons who are under 
great mental strain (anorexia mentalis). Polyphagia, or bulimia, may 
be permanent or paroxysmal. It is an inordinate craving for food in con- 
valescence from febrile disease and in some insanities and hysteria, etc. 
Akoria is a feeling of emptiness. Pica is a craving for unusual substances, 
observed in hysteria, idiots, and children. Thirst may be increased or 
annulled in fever, in diabetes, or from a dry mouth. Idiosyncrasies are 
aversion to certain foods. 

Other sensory phenomena are ancesthesia, hyperesthesia, paresthesia, 
nausea, and abnormalities of appetite. 

Secretory Phenomena of the Stomach 

Gastric Juice. — Healthy individuals may have a small quantity of 
gastric juice in an empty stomach. When this quantity is increased, we 



264 



THE DIGESTIVE SYSTEM 



speak of supersecretion with or without hyperacidity (1 to 2 per cent). 
Such conditions are known to be present in chronic dyspepsia, in neuras- 
thenia, and in serious nervous disease, such as locomotor ataxia. Therefore 
not every case of dyspepsia has its origin in the stomach or requires local 
treatment. Stomach supersecretion may be a distinct nervous manifesta- 
tion similar to salivation in bulbar paralysis. Superacidity without super- 
secretion is a common occurrence in ulcer of the stomach. Supersecretion 
and superacidity are usually associated with pain, vomiting, dilatation of 
the stomach, and cachexia. 

Injuries of the stomach mucosa or a localized venous thrombosis are 
apt to turn into peptic ulcer when supersecretion is present. Mycotic 
necrosis is another potent factor in the causation of peptic ulcers. 

Stagnation. — Stagnation of the stomach contents favors microbiotic 
action. If stagnation and free HC1 go together, putrid fermentation is 
rare. Stagnation and anacidity favor putrid action. When undue fer- 
mentation exists without motor or secretory disturbances, the quality 
and quantity of food are usually at fault and the cause of dyspeptic 
symptoms. 

The secretory neuroses are called gastrosuccorrhoza, hyperchlorhydria, 
hypochlorhydria, and nervous dyspepsia. 

Hydrochloric Acid, HCl 

Hydrochloric acid is secreted by the stomach and combines with the 
various stomach contents, notably the proteids. The carbohydrates are 
acted upon by the saliva. In healthy adult stomachs HCl is secreted in 
such quantities that it can be detected as a free acid. In young infants 
this is not the case. During the height of digestion free HCl reaction 
is present. 

Hyperacidity. — Continuous hyperacidity is found in chlorosis and in 
neurotic dyspepsia, is often present in simple ulcer, and may be a symptom 
of the early stages of chronic gastritis. It speaks against carcinoma except 
when a simple ulcer is undergoing carcinomatous metaplasia. 

Subacidity. — Continuous subacidity under 1 per cent is found in chronic 
gastritis, especially with dilatation and atony, in some cases of simple ulcer 
with chronic gastritis, and in incipient carcinoma. It is also found in 
anaemia, tuberculosis, and other cachexias. A decrease of HCl interferes 
with the splitting up of the proteids and decreases the antiseptic action of 
the gastric juice. 

Anacidity. — Anacidity is a persistent symptom of the later stages of 
chronic gastritis, when pepsin is also lacking. When pepsin is present, 
it indicates a neurosis. In combination with other signs anacidity speaks 
for carcinoma. 

A true anacidity is rare, but has been observed in cases of achylia gastrica. 

Therapeutic Value of Hydrochloric Acid. — The gastric juice possesses 
antiseptic and germicidal properties. These properties are referable to 
the presence of free HCl. A subnormal amount of HCl will call forth an 
increased amount of intestinal putrefaction (subacidity, anacidity). A 
normal acidity of the gastric juice is never associated with increased 



DIGESTIVE FERMENTS 



265 



indicanuria, except in ulcer, when hyperchlorhydria and increased indica- 
nuria go together. 

For supplementing the digestive work of the stomach and improving 
the appetite, the author has used HC1 for twenty-five years of his professional 
life in adults and in children over two years of age, and there is no drug in 
the pharmacopoeia which has given him more satisfaction. The indication 
has been a coated tongue, irrespective of the underlying condition, and 
even in cases of fermentative dyspepsia with acid eructation, the adminis- 
tration of HC1 has been followed by far happier results than resulted from 
the administration of alkalies. No amount of theoretical reasoning will 
dispose of clinical experience. In only a few cases will the HC1 not be 
tolerated, and if the tongue fails to become clean after its use, there is usually 
some grave organic change in some organ. In the presence of hyperchlor- 
hydria HC1 is not indicated. 

Hydrochloric acid favors proteolytic action of the pancreatic juice 
(Rachford), and the therapeutic administration of hydrochloric acid to 
aid digestion finds an additional indication by reason of this fact. The 
beneficial action of hydrochloric acid is not confined to the stomach, but 
as combined hydrochloric acid it is continued in the intestinal canal, where 
it not only aids the pancreatic digestion of casein, but also acts as an in- 
testinal antiseptic. For the mode of administration, see chapter on 
General Therapeutics. 

Bitter tonics, such as mix vomica, strychnine, quassia, gentian, and 
quinine may be given in combination with HQ. 



The principal digestive ferments are ptyalin, pepsin, and pancreatin. 

Ptyalin. — Ptyalin may be practically discarded, for we know very little 
as yet about the altered chemistry of the saliva. Amylaceous dyspepsia 
will hardly exist in a person who chews slowly. The market is flooded with 
preparations of diastase, pure or in combination with laxatives, tonics, 
and antiseptics, but the author is unable at the present time to give exact 
indications for their use. The pineapple also contains a ferment which can 
be administered as pineapple juice. 

Pepsin. — Marked diminution of this principle or its absence indicates 
a corresponding disturbance of glandular activity. It may exist with a 
variety of lesions. 

Pepsin acts in an acid medium (hydrochloric acid) ; pancreatin acts in 
an alkaline medium. 

Pancreatin. — Pancreatin is practically indicated only in atrophic gas- 
tritis. 



M. Sig. : After meals. 

Other Aids. — Artificial means of aiding digestion (other than HC1) 
are too readily prescribed and ordered at random. In ordinary nervous 
dyspepsia it is best to stimulate the stomach secretions by putting solid 



Digestive Ferments 




gr. vnj. 



266 



THE DIGESTIVE SYSTEM 



food into the stomach and aiding digestion with a few drops of dilute hydro- 
chloric acid, to be taken in water after meals, not by administering digestive 
jerments. In a case of bilateral parotitis with a dry mouth and no flow of 
saliva the writer has given malt and taka diastase to advantage. 

Lactic acid is not a normal product of stomach digestion. It is often 
ingested with food and forms early in digestion when milk and bread have 
been taken. It is present in larger proportions in dilatation with stagnation 
of contents. If associated with retention and absence of HC1, it makes 
the suspicion of carcinoma strong, but its presence is not pathognomonic 
of carcinoma, because it is also found in functional stomach disorders and 
in gastritis gravis. 

Zymogen. — The production of zymogen is a staple function of the 
stomach mucosa. 

Alkalies neutralize gastric acidity and are supposed to stimulate gastric 
secretion. It is the author's experience that in fermentative dyspepsia 
with acid eructations (fatty acids) without pain, a brisk laxative, followed 
by HC1, is superior to the alkaline management. In hyperacidity and 
ulcer and various forms of dyspepsia with pain after eating the alkalies are 
indicated. Alkalies are indispensable in lavage to dissolve mucus in the 
stomach. The beneficial effects of alkaline mineral waters (Carlsbad, 
Ems, Vichy, Saratoga) are most marked in those cases in which diet, ex- 
ercise, massage, hydrotherapeutics, and freedom from worry are secured. 
Bismuth subcarbonate, magnesium carbonate, and sodium bicarbonate 
are the alkalies usually administered. Alkalies may be combined with 
morphine for the purpose of overcoming severe pain. 

Diagnostic Technique. (See also Laboratory Aids.) 

We determine the location, size, and capacity of the stomach by per- 
cussion, palpation, and auscultatory percussion. The fundus is the highest 
point in the stomach and reaches the level of the ninth dorsal vertebra. 
The lesser curvature is usually covered by the liver; the upper greater 
curvature is covered by the lung; the pylorus is covered by the right lobe 
of the liver. 

Gastric distention can be made out by inflating the stomach. The 
patient swallows a teaspoonful of sodium bicarbonate in eight ounces of 
water, and immediately half a teaspoonful of tartaric acid in the same amount 
of water. An evolution of C0 2 takes place in the stomach, and the organ 
stands out prominently and can readily be palpated or percussed. Loca- 
tion, size, and capacity determinations are more or less fallacious, but can 
be made by auscultatory percussion (Platschergerausch splashing sound). 
Gastrodiaphany, or transillumination of the human stomach by means 
of a swallowed small electric lamp, was first practised by Dr. Einhorn, of 
New York. 

Transillumination of the stomach with fluorescein was introduced by 
Kemp and Lincoln, of New York. It may be used in stout as well as thin 
persons with good results; even in the colored race the results are fair. 
The method employed is as follows: Give the patient 10 gr. or more of 
quinine during the day of examination or the day previous. Introduce 



DIAGNOSTIC TECHNIQUE 



267 



the lamp. Have the patient drink a glass of water in which has been 
dissolved 30 to 40 gr. of sodium bicarbonate, to render the gastric contents 
alkaline. Allow another glass of water to be taken, into which has been 
placed I gr. of fluorescein, 1 dr. of glycerin, and 20 gr. or more of sodium 
bicarbonate. The abdomen being bared, conduct the patient into the dark 
room, or, if at night, simply turn out the lights. It is better to introduce 
the lamp before the solution, so that should there by any chance be any 
trouble, the fluorescein will not be vomited. 

X Ray Examination. — By introducing a soft rubber tube with a me- 
tallic chain in its centre, the location of the stomach can be ascertained 
as a shadowgraph. Bismuth powder thrown into the stomach with a 




Fig. 108. — Illumination of the Stomach by means of Fluorescein 
and the Electric Light. 



powder blower might facilitate the taking of an x ray stomach shadow. 
Illumination of the stomach by means of radium is unsatisfactory. 

Method of Testing the Motor Function of the Stomach. — The peristaltic 
function of the stomach is the most important one, because the secretory 
and resorptive function of the stomach may be assumed by the intestines. 
When the motor function of the stomach is interfered with, food must 
remain in the stomach and accumulate and finally be vomited as in pyloric 
stenosis. There are six or seven methods of testing the motor functions 
of the stomach. The simplest for the general practitioner are the tests 
of Leube and Ewald. 

Leube's Test. — Give a test breakfast and ascertain by means of the stom- 
ach tube after two hours whether solid contents are still to be found in the 



268 



THE DIGESTIVE SYSTEM 



stomach. When the tube is in the stomach the patient strains as if at stool. 
If no contents arise, push the tube in or out and use external pressure over 
the stomach. If nothing arises, the stomach is empty or the tube is blocked 
by large portions of food. To ascertain the latter, pour in half a pint of 
water through a funnel. If nothing but water returns, the test meal has 
passed into the intestines. 

Ewald's Test. — Give one grain of salol. Normally it can be recognized 
in the urine in from forty to seventy-five minutes. Delay in its appearance 
will indicate a retardation of the passage of food into the intestine. It is 
recognized in the urine by the violet color produced on the addition of 
neutral ferric chloride. 

The "schltjckgerausch," heard at the ensiform cartilage, is of diag- 
nostic import in stricture of the oesophagus and cardia, but in the absence 
of such lesions it is a variable phenomenon. 

The chemical examination of the stomach contents is made by siphoning 
out the stomach after a test meal and applying the tests as given in the 
chapter on Laboratory Diagnosis. 

Ewald and Boas Test Breakfast. — One piece of wheat bread, one 
pint of water or tea without milk or sugar. Time for examination, one 
hour after the meal. 

Leube and Riegel Test Dinner. — A plate of soup and a portion of 
roast beef. Time for examination, three to four hours after meal. 

Fleiner's Test Meal. — Soup, roast beef, and potato puree. Time 
for examination, three to four hours after meal. 

Double Test Meal. — 8 a.m. Two and a half ounces of scraped and 
broiled beef, one soft boiled egg, one ounce of boiled rice, one glass of milk, 
a piece of bread. 

12 m. Follow at noon by Ewald's breakfast. Examine one hour later. 

Gross Interpretation. — The absence of all proteids and the presence of 
carbohydrates, rice, and bread point to hyperchlorhydria. The presence 
of the entire meal, with milk uncurdled, means impaired motility, atrophy 
of the mucosa, or absence of acid. (See also Laboratory Diagnosis.) 

To Test Gastric Resorption. — Method of Penzold and Faber: Five 
grains of potassium iodide are swallowed in a wafer with three and a half 
ounces of water. It can be detected in the saliva and urine in from six 
and a half to eighteen minutes by means of starch paper, which, when wet 
with saliva or urine and touched with fuming nitric acid, shows the blue 
iodine reaction. There is a reduced absorption in carcinoma. 

For Sahli's test for gastric absorption see Laboratory Aids. 

REMARKS ON THE CLINICAL PATHOLOGY OF THE INTESTINE 

Experiments have shown that in the absence of bile in the intestine 
proteids and carbohydrates undergo their usual metabolic changes, and 
about 60 per cent of fats are not absorbed. They are split up by bacteria 
and by the pancreatic juice, and their products irritate the intestine. Thus 
fats are harmful in the absence of bile. Bile has a certain antiseptic power 
over intestinal bacteria, and as the absence of bile favors constipation, an 
overproduction of bacteria results. The absence of pancreatic juice in 



MOTOR PHENOMENA OF THE INTESTINE 



269 



the intestine is rare. There are two openings of the pancreatic duct. The 
duct is seldom closed by concrements, and a complete degeneration of the 
organ is rare. We have no very reliable data regarding the behavior of pro- 
teids and carbohydrates in the absence of pancreatic juice, but it is certain 
that much of the fat taken into the body is found unchanged in the faeces. 

The intestine receives from without with the food and drink a great 
variety of substances, including pathogenic and non-pathogenic bacteria, 
and behaves toward them according to condition and idiosyncrasy. Food 
ptomaines are absorbed by the intestine and injure it or poison the organism. 
Many bacteria which get into the stomach are killed therein, others lose 
their virulency, and still others go unchanged into the intestine. Those 
able to withstand an acid medium become active in the small intestine; 
others thrive in neutral or alkaline media and develop in the colon, where 
there is less peristalsis. 

An invasion of the organism by bacteria is hindered by an intact epithelial 
lining, but soluble products of bacterial action are absorbed and may offer 
to the organism a protection against the bacteria themselves. Patho- 
genic bacteria may die in an acid stomach or pass through the intestine 
and fail to find a foothold in the intestinal mucosa. The cholera vibrio 
is particularly virulent in dyspeptics with subacidity. 

The substances which originate in the intestine and irritate the same 
are lactic, butyric, and acetic acids, sulphureted hydrogen, aromatic bodies, 
bacterial poisons, and ptomaines. The frequent complication of nephritis 
in the course of intestinal troubles is due to the absorption of poisons. In 
endemic dysentery protozoa (amoeba) have been found in the intestine. 

Absorption of nutritive material takes place principally in the small 
intestine. Sugar and albumen are taken into the blood, and fat is taken 
into the lymphatics. In diseased conditions the power of absorption is 
lessened, and diarrhoea results. In some forms of diarrhoea the liquid stools 
are due to increased transudation of the intestine 

Motor Phenomena 

Singultus, or hiccough, results from sudden contraction of the diaphragm. 
The mild form of hiccough is of little importance, but its occurrence in 
serious illness adds to the gravity of the prognosis. (See also chapter on 
General Therapeutics.) 

Nervous constipation and nervous diarrhoea are discussed under Con- 
stipation and Diarrhoea. 

Enterospasm and proctospasm are contractures of the muscular fibres 
of the intestine and rectum, with and without pain, causing transient 
constipation or obstruction of the bowel. 

Peristaltic unrest and retroperistalsis are motor phenomena of the in- 
testine observed in bowel obstruction and also in neurotics. 

Atony of the intestine is frequently observed in atrophic and rhachitic 
infants, in neurasthenic adults, and in paresis and paralysis of the intestinal 
muscularis from local or central cause. The abdomen is usually tympanitic, 
and auscultation shows absence of gurgling gut sounds, moreover, the 
intestine does not empty itself, 



270 



THE DIGESTIVE SYSTEM 



Sensory Phenomena 

Colic and painful crises are frequently observed. When gall stones and 
renal colic can be ruled out, there may be intestinal colic from various 
causes — flatulence, appendicular colic, lead colic, mucous colic, and crises of 
nervous disease. 

Rectal neuralgia without appreciable local cause is observed in anaemic 
and neurotic individuals. (See Rectum.) 

Secretory phenomena, such as nervous diarrhoea and colica mucosa, are 
discussed clinically. 

Diagnostic Technique. (See also Laboratory Aids.) 

Inspection. — Simple inspection of the abdomen may show enlargement, 
retraction, and venous distention, if either of these conditions is present. 
Exaggerated contraction is noticeable through the abdominal walls. When 
there is undue relaxation the belly flattens out when the patient is on his 
back, and falls downward like a half filled sack when the patient stands 
(enteroptosis). 

Palpation should be done in a warm room, and in some instances a 
relaxation of the abdomen is best secured by placing and examining the 
patient in a warm bath or anaesthetizing him. Palpation elicits a gurgling 
sound and a splashing sound over the stomach or colon. Tumors are 
intraperitoneal and extraperitoneal, and phantom tumors can be indented 
by pressure. Where there is inflammation, pain or tenderness is elicited 
on pressure and also a feeling of resistance when the parts are lax. 

Palpation of the appendix and incidentally the kidneys is readily possible. 
These organs can be felt in children and adults in most cases in which a care- 
ful search is made. 

Percussion is less important than palpation. A distended gut gives a 
tympanitic sound; a collapsed gut or one filled with liquids or solids shows 
dulness. An abdominal effusion changes its position with the changed 
position of the patient, unless it is encysted or confined by adhesions. 

Auscultation reveals undue or absent peristalsis and the gurgling and 
splashing sound, but furnishes no valuable data otherwise. The rectum 
may be explored by the finger protected by a finger cot, or by means of a 
speculum and light. 

Transillumination after a cleansing enema has little practical value. 

An x ray examination of the lower gut can be made with the aid of a 
wire encased in a soft rectal tube, which can be inserted up to the sigmoid 
flexure, or by means of a high injection of starch water in which subnitrate 
of bismuth is suspended. Such a fluid will gravitate to the colon in the 
dorsal posture with the hips elevated. 

Inflation of the lower gut by means of an inverted siphon or by injecting 
air with a bicycle pump is easily accomplished. An inflated colon will lie 
in front of a kidney tumor or retroperitoneal glands and behind or below 
an enlarged spleen. The colon can be inflated by gas, water, or oil in the 
genupectoral poskion. (See also Laboratory Diagnosis.) 

Examination of the Faeces. — The quantity, consistence, and character 
of the faeces vary. In the small intestine the stool is liquid ; its consistence 



DIAGNOSTIC TECHNIQUE 



271 



and form are attained in the colon. If there is rapid peristalsis or increased 
secretion in the colon, the stools are also liquid. Decreased secretion will 
favor dry stools. In chronic constipation the stool forms into small 
scybala. Spastic constipation or stricture may furnish a small calibre 
stool. The color is influenced by what has been taken into the stomach 
(iron, bismuth, blackberries, etc). 

Gmelin's bile reaction is not found in the feces normally. When found 
it indicates a disturbance in the small intestine and rapid peristalsis. Gray 
stools indicate an absence of bile in the intestinal tract, but it should be 
borne in mind that gray stools are also observed in tuberculosis of the intes- 
tines, in leucaemia, and in carcinosis. Vegetables and milk give an abundant 
stool. The reaction of the feces is alkaline except in fermentative diarrhoea. 
Lientery is that condition in which remnants of food or fat or starch are 
found in the stools. Starch in the stool in considerable quantities is always 
pathological. We may find in the stool remnants of food, found in every 
stool (starch rarely); fragments of tumors and tissues (carcinoma, dysen- 
tery); concretions — enteroliths, coproliths, gallstones, foreign bodies; pus in 
abscess, dysentery, or syphilitic, tuberculous, or carcinomatous ulceration; 
blood, in injury, endarteritis, infection, intoxication, congestion from dis- 
turbed circulation, haemorrhoids, and ulceration. When small quantities 
of blood are found in the stools of typhoid fever patients, we should be 
on the lookout for profuse haemorrhages. Blood from the stomach or duo- 
denum is usually black or tarlike. 

Mucus may be of vegetable origin and resemble frog spawn. It is 
usually the product of irritation and catarrh of Lieberkuhn's glands. No 
mucus, no catarrh. Colica mucosa is observed in neurotics. Yellow 
mucus (bile) means catarrh of the small intestine (duodenal catarrh). 
Mucus in the stools may indicate constipation, piles, enteroptosis, worms, 
intestinal adhesions, or nervous colic. 

Fibrin. — Membranes in the stools are generally mucus. Erhlich's 
triacid solution colors mucus green, fibrin red. (See Laboratory Aids.) 

Fat is always found in drops or crystals. Large quantities are found in 
defective absorption, in fat diarrhoea of children, and in hepatic and pan- 
creatic disease. 

Bile. — Normally there is no bile reaction in the stools. When it is 
present it indicates catarrh of the small intestine. The stools of children 
colored green by bile resemble "green bacillus " stools. 

Parasites. — Worms, protozoa, amoeba. 

Crystals.— The so called Charcot crystals speak for worms in the in- 
testine. 

Bacteria. — In the present state of our knowledge no exact clinical de- 
ductions can be drawn from the enormous number of bacteria found in 
the stools, except when cholera, typhoid, tuberculosis, or bubonic microbes, 
etc., are found. 

For careful investigation of the stools the employment of a stool sieve 
is necessary. (See Laboratory Diagnosis.) 

For lavage, flushing the colon / and enteroclysis, see chapter on General 
Therapeutics. 



272 



THE DIGESTIVE SYSTEM 



CONCLUSIONS 

It is admitted by the majority of clinicians that a chemical examination 
of the stomach contents is of minor practical importance as compared with 
a good insight into the motor function. To rely upon secretory phenomena 
in forming a diagnosis, prognosis, and treatment is a grave mistake. The 
early recognition of organic stomach disease is of great importance, and in 
long standing dyspepsia with considerable loss of weight and in the absence 
of a palpable tumor or stricture an examination under narcosis or an ex- 
ploratory laparotomy is justified. 

The introduction of a stomach tube is usually contraindicated in the 
advanced stages of heart disease, in aneurysm, pulmonary haemorrhage, 
advanced cachexia, pulmonary tuberculosis, apoplexy, cerebral hyperaemia, 
and ulcer of the stomach with recent hsematemesis and dark stools, or when 
the stomach mucosa easily bleeds. 

In summing up, we may state that the gastroenteric tract has a triple 
function: Mechanical, chemical, and absorptive. Any disturbance of 
these functions is followed by a simple or inflammatory dyspepsia and 
malnutrition. Fermentative and putrid changes in the mouth may travel 
into the stomach and intestines. It is of importance to know whether a 
disturbance of digestion is due to infection or motor disturbance or is of 
neurotic origin, and it is important to remember that the susceptibility 
to infection and catarrhal conditions of the gastroenteric tract is different 
in different individuals, and thus we have clinically weak and strong stomachs. 



CHAPTER VIII 
THE DIGESTIVE SYSTEM — Continued 

GASTROINTESTINAL AILMENTS IN ADULTS 

Synopsis: Acute Dyspepsia and Gastritis, Diet, Medication. — Chronic Dyspepsia with and 
without Dilatation and Atony, Varieties, Specimen Diet, Treatment. — Dyspepsia of 
Pregnancy. — Secretory Neuroses of the Stomach. — Erosion and Ulcer of the Stomach, 
Clinical Varieties of Ulcer. — Cancer of the Stomach. — Benign Tumors. — Haemorrhage 
from the Stomach. — Gastrointestinal Neuralgia, Cardialgia, Gastralgia, Enteralgia, 
Colic, Stomach Cramps, Differentiation, Treatment. — Indications for Operation of the 
Stomach. — Constipation and Faecal Impaction. — Faecal Tumors. — Diarrhoeas and In- 
continence, Clinical Forms. — Tympanites and Dilatation of the Colon. — Inflammatory 
Disorders of the Intestines, Acute and Chronic. — Enteritis. — Gastroenteritis and 
Dysentery. — Dysentery. — Ulcer of the Intestines. — Appendicitis, General Indications 
for Operation. — Neoplasms of the Intestines. — Bowel Obstruction. — Haemorrhage 
from the Intestines. — Remarks on Strangulated Hernia and Taxis. — Intestinal 
Parasites. — Hook Worm Disease. — Enteroptosis. — Intestinal Indigestion, Treatment 
by Diet, Exercise, Baths, Medication. 

ACUTE DYSPEPSIA ; ACUTE INDIGESTION ; GASTRICISMUS 

Etiology. — The disease is due to dietetic imprudence, overeating, un- 
suitable or decomposing food or abuse of alcoholic beverages. 

Symptoms. — Headache, a dull feeling, epigastric fulness, dull pain in 
epigastrium, nausea, eructations, vomiting, coated tongue, fcetor ex ore, 
a bad taste in the mouth. The attack may last from two to five days. 
Constipation or diarrhoea may be associated with acute dyspepsia. 

Treatment. — Diet. — Carbonated water, slimy soup, meat broth or beef 
tea, peppermint tea or black tea, or total abstinence from food for from 
twelve to twenty-four hours. 

Medication. — Five to ten grains of calomel followed by a saline cathar- 
tic, and on the following day five drops of dilute hydrochloric acid in sugar 
water, four times a day, and a long walk in the fresh air. 

Prognosis favorable. (For acute indigestion in children, see Paediatrics.) 

Acute Gastritis, Simple, Phlegmonous, Toxic, ^Infectious, Parasitic 

This is the severe form of acute dyspepsia. There are, in addition to 
the ordinary symptoms mentioned above, pain, tympanites, high colored, 
scanty urine, and occasionally slight jaundice. The management is the 
same as in ordinary acute indigestion, but a strict diet will have to be kept 

273 



274 



THE DIGESTIVE SYSTEM 



up for a longer period, and in addition the following prescription is very 
serviceable to control pain and vomiting in adults: 

1$ Morph. sulph., gr. j; 

Aqua? amygd. amar., ) __ 
Tinct. valerian, aether., } ' 

Aquae carbonicae, ad, §v. 

M. S.: One half to one tablespoonful every two hours. Keep on 
ice. Do not shake the bottle. 

In some cases morphine should be given hypodermically. 

In addition to simple acute gastritis, there are the phlegmonous gas- 
tritis secondary to cancer or septic peritonitis and other processes, toxic 
gastritis from the ingestion of corrosive poisons (see Poisons), infectious 
gastritis, which is observed during severe infectious disease (scarlatina, 
etc.), and a parasitic gastritis, or mould in the stomach. 

Prognosis. — The prognosis of all forms of severe gastritis will depend 
upon the underlying cause. In the very young and the aged or in cachectic 
individuals the prognosis is very grave. 

Treatment. — The treatment is symptomatic, as in acute simple gastritis. 



CHRONIC DYSPEPSIA 

Dyspepsia, although only a symptom indicating a disturbance of some 
kind, rises in practice, like convulsions, to the dignity of an ailment. The 
laity invariably associate the symptom "dyspepsia" with the stomach 
proper, and thus the stomach specialist may bask in the sunshine of all the 
ills that flesh is heir to, because all sickness is accompanied more or less 
by dyspepsia or a loss of appetite. 

It is the duty of the physician to make a careful clinical examination 
of his patient in long standing dyspepsia, and after excluding heart, lung, 
kidney, liver, brain, and nerve disease, he will finally come by exclusion 
to the consideration of a primary dyspepsia having its origin in some dis- 
order of the gastroenteric tract, and our modern methods of examination 
will enable him to tell whether he has to deal with an inflammatory or 
secretory disturbance or a motor insufficiency (muscular or stenotic) or 
ulcer or new growth. 

When dyspepsia is secondary to, or concomitant with, other organic 
disease, our efforts to overcome dyspepsia will be futile unless we recognize 
and direct our therapeutic efforts to the primary ailment. We must 
always bear in mind that chronic indigestion must be viewed in its relation 
to the whole gastroenteric tract, and not in relation to the stomach alone. 

Clinical Varieties of Chronic Dyspepsia 

Chronic Gastric Catarrh. — The primary causes of this ailment are dietetic 
errors and the excessive use of alcoholic beverages. It may be secondary 
to any chronic constitutional or organic disease of the heart, lungs, liver, 
kidneys, etc. 

Symptoms. — There may be general malaise, coated tongue, bad taste in 
the mouth, metallic taste, headache, vertigo, fickle appetite, epigastric 



CHRONIC DYSPEPSIA 



275 



oppression after eating, or "heartburn," local tenderness, eructations of 
bitter fluid, belching of gas, tympanites, vomiting after meals, morning 
vomiting or dry retching of watery mucus in alcoholism. Constipation 
and diarrhoea may alternate. Palpitation of the heart is common, and 
a "stomach cough " is generally due to chronic pharyngitis. The urine 
is usually high colored and shows a heavy deposit. 

An examination of the stomach contents enables us to recognize three 
forms of chronic gastritis: 

1. Simple Chronic Gastritis. — HC1 diminished. Fasting stomach con- 
tains a little slimy fluid. 

2. Mucous Gastritis. — HC1 diminished. Large amount of mucus present. 

3. Atrophic Gastritis. — HC1 and pepsin absent. Fasting stomach empty. 
The symptoms of atrophic gastritis resemble those of cancer (tumor 
absent) or pernicious ansemia and are accompanied by pain, vomiting, and 
progressive emaciation. 

The prognosis of chronic gastric catarrh is good, but it will take time 
to effect a cure. If atrophy has taken place, the prognosis is unfavorable. 

Treatment. — When the diagnosis of chronic gastric catarrh is made, 
the patient may take one dose of podophyllin as follows: 

Podophylli, gr. 



M. Sig. : Take at bedtime. 

Every morning before breakfast the patient should sip a cup of hot 
water in which is dissolved a teaspoonful of Carlsbad salt in case of chronic 
constipation. Should the Carlsbad salt not agree with the patient, an 
enema or a " lapactic " pill may be taken before going to bed. As a rule 
cases of chronic gastric catarrh do not improve unless the bowels move 
freely once a day. 



On rising, one cup of hot water. 

8 a. m., one bowl of slimy soup with or without egg, or two scrambled 
eggs with toast, or two raw eggs with salt, tea, toast, zwieback. Avoid fats. 

11 a. m., one cup of bouillon with egg or eat a piece of sweet chocolate. 

12 to 1, plain soup or bouillon, raw scraped meat or lamb chop or 
scrambled eggs, fresh green salad, rice, stewed fruit, and tea. 

6 p. M., cold meat, beef, chicken, turkey, raw ham, raw oysters, caviar 
sandwich with lemon juice, raw meat sandwich, meat jelly, salt sardelles, 
buttermilk, tea, cocoa, toast, etc. 

Milk or buttermilk may be taken with any meal if it agrees. Hydro- 
chloric acid will aid digestion if taken after each large meal. HCl may be 
given in water or in combination with essence of pepsin or with bitter tonics 
(see General Therapeutics). Occasionally HCl will not agree, and then it 
will be well to give the following alkaline powder after eating: 



Calomel, 
Pulv. aromat 



gr. x; 
gr. hj. 



SPECIMEN DIET 




gr. V to X. 



19 



276 



THE DIGESTIVE SYSTEM 



Beer should be forbidden. A glass of Rhine or Moselle wine or a tea- 
spoonful of whiskey in water after meals may be allowed as an experiment. 
At the same time the patient should have exercise (walking, bicycling, 
punching bag, horseback riding), and should be free from worry; if 
necessary, he should go away from home to secure it. General mild 
massage and vibratory massage of the stomach are very important adjuvants 
to the treatment, also warm baths or cool douches. As the patient improves, 
the diet may be more liberal, avoiding dense cheese, fried potatoes, fatty 
sauces, cabbage, beans, mayonnaise, beer, pastry, and raw fruit. Contrary 
to universal prejudice, the writer has only occasionally found it necessary 
to eliminate from the diet salt pickles, green salads, and soft mature cheese. 

When such management fails to improve the patient, stomach washing 
is indicated, particularly in cases with much mucus in the stomach. Two 
to three quarts of warm water containing half an ounce of bicarbonate of 
sodium are used. The best time to wash the stomach is one half to one 
hour before breakfast. Stomach washing may be continued for from 
two to six months. (See General Therapeutics.) 

DYSPEPSIA WITH DILATATION OR ATONY OF THE STOMACH 

There are three varieties of stomach dilatation: 1. Acute dilatation. 2. 
Dilatation due to stricture or narrowing of the pylorus or duodenum, malig- 
nant or non-malignant. 3. Dilatation due to chronic gastric catarrh or 
habitual overdistention (beer drinkers, overfeeding of infants) and degenera- 
tive changes from wasting disease. 

Symptoms. — Anacidity, hyperacidity, and normal acidity may be asso- 
ciated with dilatation. In addition to ordinary dyspeptic symptoms, 
we notice a characteristic vomiting of large quantities of stagnant fluid. 
The vomit is acid, from the presence of lactic, butyric, and acetic acids, 
and offensive to the smell. The fluid contains particles of food, the Sarcina 
ventriculi, yeast fungus, and bacteria. Auscultatory percussion and in- 
flation by air or transillumination will determine the outlines of the stomach, 
and a splashing and succussion sound may be elicited by the hand. 

Finding a tumor will decide against the atonic nature of the dilatation, 
and in the majority of cases the tumor is cancer. The distinction of benign 
from malignant tumor can be made only by operative inspection. 

The prognosis depends upon the cause. 

Treatment. — In atony due to stricture at the outlet of the stomach 
operative interference is the only help. If the stricture cannot be removed, 
the stomach may be joined to the intestine (gastroenterostomy). In the 
atonic variety lavage, enemata, a dry diet, and vibratory massage are 
the important elements of treatment. As myasthenia is not uncommon 
in students and persons leading a sedentary life, an active out of door life 
should be encouraged. In enteroptosis an abdominal binder should be worn. 

SPECIMEN DIET FOR DILATATION 

Scraped meat, scraped ham, smoked beef, game, fowl, soft eggs, cereals 
(all kinds) and cream, beef, or meat jelly, extract of malt, boiled beef, 
oysters, raw or stewed, puree of potatoes, lentils, peas, omelette souffle, 



CHRONIC NERVOUS DYSPEPSIA 



277 



zwieback, crackers, toast, caviar, cocoa, chocolate, tea, tropon, Tokay or 
Malaga wine, whiskey in teaspoonful doses in water. 

Other articles may be selected from the general diet lists. The 
amount of liquids taken should not exceed three pints in twenty-four 
hours. In some instances rectal feeding becomes necessary for a time, 
particularly in severe vomiting and pain. 

Medication. — Hydrochloric acid or tincture of nux vomica is to be 
given after eating. Morphine subcutaneously may be necessary in extreme 
cases with excruciating pain. Strychnine in dilute phosphoric acid, gr. 1 
ad §j, ten drops three times a day, is useful. Massage and vibratory 
massage and hydrotherapy (cold douche or spray to the region of the 
stomach) are of great importance. Some patients do well by wearing a 
moist towel around the abdomen day and night (Neptune's girdle), and 
in other cases an abdominal bandage gives comfort and relief. 

Operative Treatment. — In otherwise incurable simple atonic dilata- 
tion excision of a part of the stomach wall (gastroplication, or gastror- 
rhaphy) has been done. Before operating upon the stomach proper, we 
should be absolutely certain that the obstruction to the flow of chyme is 
not somewhere outside of the stomach. 



CHRONIC NERVOUS DYSPEPSIA 

Nervous dyspepsia is a generic name covering sensory, motor, and 
secretory neuroses. Neurasthenic individuals generally have some special 
organ which gives them particular trouble. The stomach neurasthenic 
has many or all of the symptoms enumerated under dyspepsia, and is a 
hypochondriac in addition. But in spite of these symptoms the stomach 
is found to be empty six or seven hours after a full meal, showing that there is 
no stagnation in the stomach. The gastric juice is usually normal, but it 
may be increased or diminished. In nervous dyspepsia there is very little 
epigastric tenderness, and usually a powerful throbbing of the abdominal 
aorta, particularly in women, is noticed. 

Diagnosis. — The diagnosis rests upon a recognition of the existence of 
a neuropathic constitution and the absence of organic disease. The distinction 
of nervous dyspepsia from ulcer becomes difficult only in those cases in 
which there has been no vomiting of blood. In ulcer gastric pain is regularly 
dependent upon eating, and there are circumscribed pain points in the 
epigastric region and in the back. In chronic gastric catarrh there is much 
vomiting of mucus, occasionally blood streaked. In cancer the distress 
is present, with and without food in the stomach, and HQ secretion is 
usually absent. 

Prognosis. — The prognosis in nervous dyspepsia is favorable. 

Treatment. — Correct bad habits, hunt up and remove the underlying 
cause, such as floating kidney or enteroptosis (abdominal binder). Enjoin 
rest from mental and bodily overwork, urge change of environment and 
employ gymnastics, general massage, and static electricity. Stomach 
washing is not indicated in nervous dyspepsia. 



278 



THE DIGESTIVE SYSTEM 



Diet. — There is no orthodox diet for nervous dyspepsia. A liberal 
mixed diet is to be advised, avoiding cabbage, pastry, rich dressings, beans, 
pears, fried oysters, and clams. A purely liquid diet and peptonized food 
are to be condemned for this class of cases. As regards diet, the statement 
must be most emphatically reiterated that no ironclad rules can be given. 
A fluid diet is to be avoided if possible, and the patient's tastes and idiosyn- 
crasies are to be taken into consideration. It is a better plan to start 
with a liberal miscellaneous diet, and gradually eliminate articles which 
disagree, than to start with fluid or peptonized food and gradually build 
up. The bowels should move daily. If the tongue is coated, half a tea- 
spoonful of Horsford's acid phosphates may be taken in water after meals 
or five drops of dilute hydrochloric acid. In insomnia chloral and bromide 
of potassium will be necessary occasionally at bedtime. Some neurasthenics 
sleep well if they take beer or porter with a salt cracker before going to bed. 
Nervous dyspeptics must understand that the " heart thumping " is not 
heart disease. In fact, " mind cure " applied with tact will work wonders. 
In some instances a Weir Mitchell rest cure is advisable. 

The Dyspepsia of Pregnancy is partly neurotic and partly due to cir- 
culatory disturbances. Vomiting is best controlled by chloral hydrate 
and bromides. HC1 after eating and general hygienic management are 
indicated. 

SECRETORY NEUROSIS OF THE STOMACH 

The terms super secretion, hyperacidity, anacidity, gastrosuccorrhcea, 
and achylia gastrica are employed to denote certain anomalies of secretion 
as observed in the modern analysis of stomach contents. Such disturbances 
are functional without discoverable local lesion. They may be of reflex 
origin, they may be temporary or more or less permanent, they may exist 
with and without indigestion, and they cannot be identified with any uniform 
or characteristic symptom group. Such manifestations will receive brief 
mention with the distinct understanding that they must not be looked upon 
as a separate, tangible disease but simply accepted as "conditions." 

Dyspepsia with Hyper xhlorhydria (Hyperacidity) 

One hour after Ewald's breakfast the stomach contains an excess of 
HC1 (free HC1). Three to four hours after a meal the meats are found 
digested, the starchy food is almost unchanged. This condition may show 
periodically or be continuous. 

Symptoms. — Cardinal Symptoms. — Burning pain two to three hours 
after eating, and hyperacidity. 

Points in Differential Diagnosis. — In gallstone colic the pain is 
more in the right hypochondrium and is not relieved by alkalies or food. 
In gastric ulcer, which is also accompanied by hyperchlorhydria, there is 
bloody vomit with no complete relief from alkalies. There is increased 
pain from food. In super secretion we find a large amount of gastric juice 
in the fasting stomach. 

Treatment. — Wearing of an abdominal support. General hygienic man- 
agement of dyspepsia with hyperacidity. 



EROSIONS AND ULCER OF THE STOMACH 



279 



Diet. — A generous diet with proteids in excess is indicated theoretically. 
However, some cases do remarkably well on a diet in which there is a pre- 
ponderance of cereals and fat (cream). Start with a liberal miscellaneous 
diet and gradually eliminate whatever is found to disagree. Beer, fresh 
bread, pastry, cabbage, raw fruit, and fresh oysters usually disagree. 

The medication is alkaline. Bismuth, with or without morphine, 
bicarbonate of sodium, magnesia, and alkaline waters. The bowels must 
move freely. Lavage may be necessary. 

Other Forms. — Dyspepsia and continuous or periodic super secretion of 
gastric juice in the fasting stomach have been recognized. The attacks 
come on with vomiting of acid or greenish gastric juice and pain, headache, 
pallor, and constipation. Before we stamp it as a pure neurosis and treat 
it as such (see Hyperacidity), we must exclude the gastric crises of loco- 
motor ataxia and gastric ulcer. 

Dyspepsia and Hypochlorhydria and Achylia Gastrica. — Absence of HC1 
is noticed in cancer of the stomach and in atrophic gastritis. When the 
ferments are also absent, the term achylia gastrica has been used by Ein- 
horn, of New York. An examination of the stomach contents will reveal 
the actual condition present. The administration of HC1 is indicated 
after each meal. 

EROSIONS AND ULCER OF THE STOMACH 

Peptic ulcer, duodenal ulcer is most common in women between twenty 
and thirty years of age and is often associated with chlorosis, overwork, 
and hepatic and cardiac disease. Arteriosclerosis predisposes to gastric 
ulcer. Duodenal ulcer has been observed in infants. 

Symptoms. — Dyspeptic symptoms with localized pain and vomiting 
of blood, grave ansemia, loss of weight, and hyperacidity are the character- 
istics of gastric ulcer. The pain is burning and acute and made worse by 
pressure and food. Hsematemesis occurs in 50 per cent of the cases. In 
duodenal ulcer there are localized pain, occasionally blood in the stools, 
anaemia, and loss of weight. 

Termination and Prognosis. — Gastric and duodenal ulcer may terminate 
by healing, it may perforate and cause peritonitis, it may lead to death by 
inanition or haemorrhage, or it may heal with cicatricial contracture and 
cause obstruction. The prognosis is therefore to be guarded. 

Clinical Varieties of Ulcer. — 1. Light attacks with pain, hyperacidity, 
pyrosis, no hsematemesis; 2. Severe attacks with hsematemesis; 3. Old 
chronic latent and relapsing cases with occasional haemorrhage. 

Differential Diagnosis. — Cardinal Symptoms of Ulcer of the Stomach. — 
Dyspepsia, cardialgia, hsematemesis. If hsematemesis is absent, the diag- 
nosis may be very difficult. In simple gastralgia vomiting of blood is absent 
and the taking of food gives relief from pain. Dyspepsia is usually not 
marked between the attacks of pain. Emaciation is moderate and cir- 
cumscribed tenderness is absent. In the gastric crises of tabes there is 
absence of the knee jerk, with lightning pains in the legs, and the Argyll 
Robertson pupil. Hepatic colic shows swelling and tenderness of the liver 
and frequently jaundice. Hepatic cirrhosis with hsematemesis may simu- 



280 



THE DIGESTIVE SYSTEM 



late ulcer, but will show a hard, enlarged liver and ascites. Chronic 
gastritis shows moderate pain, rarely hsematemesis, and rarely hyperacidity. 
Cancer of the stomach shows tumor, absence of HC1, and coffee ground 
vomit. Cachexia usually occurs in older people. In palpable cicatricial 
contraction near the pylorus the differential diagnosis without laparotomy 
is impossible; moreover, cancer may develop on the site of an old ulcer. 
Duodenal ulcer gives about the same symptoms as peptic ulcer. The vio- 
lent pain is often associated with tarry or bloody stools. Occasionally 
there is jaundice. 

Treatment of Gastric and Duodenal Ulcer. — Absolute rest in bed. 

Diet. — Milk, cornstarch pap, slimy gruel, burnt flour soup, tropon 
in peppermint tea, beef jelly, white of egg, custard, water ices, cream, 
and condensed milk. 

In the convalescent period, after four weeks, add scraped beef, sweet- 
breads, and farinaceous puddings. Rectal alimentation may be required. 

Medication. — Bismuth, gr. xxx, t. i. d., with or without opium, or 
morphine subcutaneously, gr. J to 

To check vomiting, cracked ice should be given and small doses of 
opium administered. 

Feeding by gavage may be necessary to overcome vomiting. 

Lavage will check obstinate vomiting. 

Surgical treatment may be necessary in the event of perforation, collapse, 
or peritonitis or for the purpose of excising the ulcer. Before surgical 
interference is attempted, the patient should have the benefit of the doubt 
and undergo antisyphilitic treatment, inasmuch as syphilis of the stomach 
has received positive recognition post mortem and should not be forgotten 
clinically. 

CANCER OF THE STOMACH 

This is generally primary, but may be secondary to cancer of neighboring 
organs. It is seldom observed before the age of forty and is decidedly a 
disease of old age. At the present time we look upon cancer as of parasitic 
origin, but we have as yet no proofs to that effect. 

Location. — Pylorus, cardia, and small and large curvatures. Metastatic 
propagation to neighboring organs is common. Perforation and peri- 
tonitis may occur. 

Prognosis and Duration. — Cancer is fatal in from one to three years. 

Symptoms and Differential Diagnosis. — The cardinal symptoms are: 
Loss of appetite, dyspepsia, pain, vomiting (coffee grounds), dilatation, 
if at the pylorus, absence of HC1, presence of lactic acid, tumor, progressive 
emaciation, and anaemia. 

The symptoms will vary according to the location of the lesion. Deg- 
lutition will be difficult in obstruction of the cardia. Cancer of the lesser 
curvature may progress without pain or vomiting. Cancer of the pylorus, 
or large curvature, will give typical symptoms and in many instances a 
palpable tumor. Palpation for tumor or undue resistance of infiltrated 
tissue is unsatisfactory in many instances for various reasons. In doubtful 
cases an examination under narcosis or an exploratory laparotomy is 
indicated. Transillumination and x ray shadowgraphs will aid in diagnosis. 



HEMORRHAGE FROM THE STOMACH 



281 



Differential Points. — The following conditions may simulate cancer of 
the stomach: Chronic gastritis. No tumor, no vomiting of material like 
coffee grounds. Gastric ulcer, with and without pyloric thickening. Tumor 
rare. HC1 in excess. Pernicious anemia. No tumor, great reduction of 
the red cells. Cancer of the pancreas. No coffee ground vomit, HC1 present, 
fat in the stools. Cancer of the colon, and of the duodenum. No coffee ground 
vomit, HC1 present. Movable kidney. No coffee ground vomit, no cachexia, 
HC1 present, characteristic shape of a palpable tumor. Impacted faces. 
Disappears under treatment. Cancer of the liver or gall bladder. No coffee 
ground vomit, HC1 present. Tumor of the abdominal wall. Extraperitoneal, 
no gastric disorder. Tumor of the omentum (tuberculous or malignant), 
no characteristic gastric symptoms. 

In the presence of so many possibilities an exact diagnosis may require 
weeks of observation unless an exploratory laparotomy is performed. 

Treatment. — Operative interference may relieve urgent symptoms, but 
will not cure the patient. Pylorectomy should be performed as early as pos- 
sible. Gastroenterostomy will facilitate the transfer of chyle. Gastrostomy 
will permit the patient to be nourished through a gastric fistula. To relieve 
pain, morphine or chloral hydrate is to be administered. A liquid or soft 
diet will give the least distress, and stomach lavage may afford temporary 
relief. 

SYPHILIS OF THE STOMACH 

This may be of the ulcerative, diffusely sclerotic, or gummatous form. 
Nothing abnormal can be detected on physical examination. Pain and 
vomiting are the only symptoms; therefore the diagnosis rests upon the 
therapeutic test, and the treatment is self evident. 

BENIGN TUMORS OF THE STOMACH 

Tumors, such as polyps, lipomata, myomata, lymphadenomata, cysts, 
gastroliths, and foreign bodies in the stomach have been observed and 
might call for operative measures. 

Non-malignant hypertrophic stenosis of the pylorus may occur in adults 
and infants (see Paediatrics) and give all the symptoms of cancer, except 
vomiting of blood. The benign stricture is recognized as such at the time 
of operative interference. Before operative treatment is carried out the pa- 
tient should undergo antisyphilitic treatment with the hope of overcoming 
a syphilitic tissue hyperplasia, which may involve any organ of a syphilitic 
patient. 

HEMORRHAGE FROM THE STOMACH 

This ailment in infants is discussed in the Paediatric Section. The blood 
vomited by adults may be red and fluid or like coffee grounds, and 
is often mixed with food. In haemoptysis the blood is bright red and 
frothy and is coughed up. In large haemorrhage into the stomach death 
may take place in a very short space of time, and only an autopsy will 
show the cause. Moderate bleeding from the stomach may be due to various 
causes, viz.: Swallowing of blood from the nasopharynx, injury, vicarious 
menstruation, gastric ulcer, gastric cancer, portal obstruction, hepatic 



282 



THE DIGESTIVE SYSTEM 



and cardiac disease, the hsemorrhagic diathesis in acute or chronic illness 
and constitutional disease or haemophilia. 

Prognosis. — Haemorrhage from the stomach is rarely fatal. 

Treatment. — The treatment of haemorrhage from the stomach for the 
time being is symptomatic. It includes absolute rest in bed, an ice bag to 
the stomach, opium by the mouth, ergotine hypodermically (gr. 2 pro dosi), 
also suprarenal extract, ice by the mouth, a ligature around one or two 
extremities, subcutaneous saline infusion in collapse, and surgical measures 
in ulcerative conditions. 

GASTROINTESTINAL NEURALGIA (CARDIALGIA, GASTRALGIA, 
ENTERALGIA, COLIC, "STOMACH CRAMPS") 

Pain in the abdominal region may be purely a neurosis. It may be due 
to overdistention and constipation, or it may be a symptom of organic 
disease, such as cancer, ulcer, intestinal tuberculosis, strangulation, or 
appendicitis, or it may be a familiar manifestation of tabes dorsalis (painful 
crises). The possibility of gallstone, lead, and renal colic in hypogastric 
pain should not be overlooked, particularly in the absence of jaundice, and 
in some cases gastrointestinal adhesions are productive of paroxysmal 
pain. Uterine and ovarian colic are often called stomachache. Grief, 
worry, overwork, anaemia, malaria, arteriosclerosis (arteriosclerotic belly- 
ache), syphilis, gout, and neurasthenia are predisposing factors in gastro- 
intestinal neuralgia. The pain is of varying character and often accom- 
panied by a feeling of faintness. Cardialgia begins in the epigastrium and 
radiates to the back, especially along the side of the stomach. It may 
last a few minutes or hours. 

Differential Diagnosis. — The following points may be borne in mind: 
Gastric crises of tabes are associated with lancinating pains, Argyll Rob- 
ertson pupil, girdle sensation, and absence of patella reflex. In ulcer 
of the stomach the pain comes on after eating and is confined to certain 
spots in the epigastrium. It is increased by pressure, and may radiate to 
the back. The vomit contains blood and a large amount of free HC1. 
In perigastritis, the sequela of ulcer, pain is not persistent and there is 
no vomiting of blood, In duodenal ulcer vomiting is infrequent. There 
is often blood in the faeces, and occasionally we notice jaundice. In cancer 
of the stomach there are pain and " black vomit." In gallstone colic the pain 
is more apt to radiate to the right shoulder. Frequently we observe jaun- 
dice, and often there is a chill with fever and swollen spleen, and pres- 
sure upward behind the ribs and behind the gall bladder elicits pain. 
The stools may be clay colored. 

In renal colic the pain usually radiates into the pubic region, and the 
urine may show blood and small calculi. 

Lead colic has a history of exposure to lead intoxication and the gums 
show a characteristic discoloration. 

In appendicular colic palpation will find the appendix painful and swollen. 

In mucous colic mucus and fibrinous shreds pass from the bowel. 

Treatment. — When pain is severe the patient should rest in bed. 
If no relief follows the application of a hot water bag or mustard plaster, 



CONSTIPATION; OBSTIPATION; FiECAL IMPACTION 



283 



and the administration of hot tea or ten drops of Hoffmann's anodyne on 
sugar, a morphine injection (gr. \ to h) should be given over the seat of 
pain and repeated if necessary. The following medicine is also very prompt 
in checking stomach pain: 



Ty Chloroformi, 5j; 

Morph. sulph., gr. j; 

Pulv. gummi arabici, 3j; 

Aquse, ad, 

M. : Ft. emuls. et adde 

Syrupi, 5jv; 

Aq. amygd. amar., 5j- 



S.: 5j every half hour until relieved. 

After the attack of cardialgia is over we should look for the underlying 
cause and endeavor to prevent a recurrence. 

The purely neurotic form of gastralgia is therefore recognized by exclu- 
sion, and for this class of cases a change of scene — outdoor exercise and 
abundant food — mix vomica and hydrochloric acid are indicated. Pain 
in the lower bowel may be eased by suppositories of opium and belladonna. 

INDICATIONS FOR OPERATIONS ON THE STOMACH 

Malignant disease should be operated upon at the earliest possible mo- 
ment. Non-malignant obstruction to the flow of chyle should be operated 
upon, provided a long continued trial of out of door life combined with 
gymnastics and massage (also vibratory massage) and antisyphilitic treat- 
ment has failed to give relief. 

Gastrotomy may be indicated for the purpose of direct inspection, for 
the removal of a foreign body, or for gaining access to a strictured oesopha- 
gus. A gastric fistula (gastrostomy) may be necessary for feeding in stricture 
above the stomach. Gastroenterostomy is indicated in otherwise " inoper- 
able " strictures of the lower stomach and duodenum and in extreme atonic 
dilatation of the stomach. Resection of the stomach in part is done for the 
removal of diseased stomach tissue. Gastroplication is an operation devised 
for atonic dilatation of the stomach without stricture, after all other means 
have failed. 

CONSTIPATION ; OBSTIPATION ; FvECAL IMPACTION 

Peristalsis carries off at regular intervals the waste products of diges- 
tion. Constipation is the opposite of diarrhoea. Two daily evacuations 
may be normal in some individuals, while others may normally have one 
movement every other day. According to the writer's experience, healthy 
individuals have on an average one movement a day. Retention of fseces 
produces local irritation and undue absorption of putrefactive poisons, 
resulting in malaise, dyspepsia, malnutrition, anaemia, etc. Primary 
ansemia may cause atonic constipation. 

Causes of Constipation. — Congenital malformations or anatomical pecul- 
iarities, benign and malignant strictures of the pylorus, bowel, or rectum, 



284 



THE DIGESTIVE SYSTEM 



loss or excitability of the mucous lining of the intestine, as in chronic catarrh, 
atrophy and adhesion following peritonitis, etc. 

Degeneration of the nervous apparatus of the intestine is frequently 
called upon to explain constipation, but we have no definite knowledge 
on the subject. It is a fact, however, that constipation is frequently found 
in neurasthenics, melancholies, and persons suffering from diseases of the 
central nervous system. Paresis of a portion of the intestine is occasionally 
productive of constipation. 

A rigid sphincter or anal fissure or painful spasm of the sphincter causes 
constipation. There may be atonic constipation from lack of secretion, 
from anaemia, from organic diseases, and from enteroptosis and flabby 




Fig. 109. — Enteroclysis. 



abdomen, which is common in women. In rhachitis we observe muscular 
atony of the bowel in children. 

We speak of spastic constipation with and without pain in neurasthenia 
and lead poisoning. We observe constipation from lack of moisture or 
lack of fat, or sugar, or from a one-sided diet (no vegetables, salads, or 
fruit), from negligence and irregularity, deferring visits to the closet, from 
lack of exercise and sedentary habits and occupation. 

Constipation may be due to internal or external hernia, to invagination 
and intussusception, and to complete strangulation of the bowel, and in 
extreme cases bile and faecal matter are vomited. 

Treatment. — Temporary or accidental constipation as caused by a 
change of diet, etc., is overcome by an enema or a laxative drug. In chronic 
constipation we study the underlying cause and treat accordingly. Correct 
any faulty diet; increase vegetables, fruits, fats, liquids. Adults should 



CONSTIPATION; OBSTIPATION; FAECAL IMPACTION 



285 



sip slowly } to J pint of cold or warm water morning and evening. Inculcate 
regular habits (also in children). Exercise in the fresh air, walking, riding, 
bicycling, tennis, golf, gymnastics, cold sponge bath, and shower baths. 
Massage of the abdomen. Automassage by means of a five to fifteen pound 
cannon ball rolled over the abdomen from right to left may be practised. 
Enemata of soap water by means of a fountain syringe and soft rectal tube 
or a piston syringe with a soft tube are useful, also suppositories of soap, 
glycerin, and gluten, dilatation of a rigid sphincter under narcosis, healing 
of anal fissures, and mineral waters, Vichy, Saratoga, Carlsbad (artificial 
Carlsbad salt in warm water), Hunyadi, Apenta, etc. Laxative drugs: Castor 
oil, croton oil, rhubarb, rhubarb and magnesia, compound rhubarb pills, 
effervescent citrate of magnesium, sulphate of magnesium, senna and 
manna, electuary of senna, compound licorice powder, tamar indien, com- 
pound infusion of senna with sodium sulphate, cascara with and without 
malt, aloes, St. Germain tea, calomel and jalap, podophyllin, strychnine and 
belladonna, lapactic pills, cream of tartar, Eno's fruit salt, iron and arsenic. 
An efficacious aloin pill is thus composed: 



1$ Aloin, 

Extr. nuc. vomic, 
Ferri. sulphat., 
Pulv. myrrhse, 
Pulv. saponis, 



aa, 



For spastic constipation warm aromatic high injections with oil are to 
be given. 

Faical impaction in the rectum calls for manual aid. Complete obstruc- 
tion demands timely surgical aid. Constipation in infants from lack of 
food (apparent constipation) may be remedied by proper feeding (see 
Paediatrics). 

When laxatives are given for any length of time, nature's remedies, 
exercise and massage, must not be neglected. In extreme cases of atonic 
constipation in children and adults the writer has known ten days to elapse 
before a movement resulted. In chronic constipation of children enemata 
may have to be given once daily for years, together with a laxative drug 
once a week. 

In enteroptosis and constipation an abdominal supporter should be 
worn. 

Stercoral, or faecal, tumors are sometimes mistaken for true tumors 
and are sometimes overlooked. They give rise to various neuralgias by 
pressure on nerves, and frequently a hot burning feeling is complained of 
by the patient which radiates from the seat of the faecal tumor in all 
directions. Persistent high enemas of soap suds and oil will remedy this 
condition. 

Migraine and obstipation offer no uniform picture, but are of frequent 
occurrence. Laxatives, hydrotherapy, and physical and dietetic measures 
are to be employed. 



286 



THE DIGESTIVE SYSTEM 



DIARRHOEA AND INCONTINENCE OF FAECES IN ADULTS 

Diarrhoea is the opposite of constipation, and is usually due to increased 
peristalsis and supersecretion of the intestine. The principal cause of diar- 
rhoea is an abnormal condition of the intestinal contents (spoilt food, gastro- 
enteric infection and intoxication), which may progress from a mild dyspeptic 
diarrhoea to catarrhal or ulcerative enteritis or choleraic diarrhoea. There 
is a psychic form of diarrhoea which does not have its origin in the intestine. 
We are all familiar with the intestinal noises and nervous diarrhoeas of 
neurotic individuals. To this group belong the sudden diarrhoeas of patients 
anticipating or dreading an examination or operation, etc. In all forms 
of diarrhoea the organism must suffer more or less, but a diarrhoea due to 
increased peristalsis of the large intestine (chronic diarrhoea due to rectal 
ulcer) is often tolerated a long time because of lesser absorption in the 
large intestine. 

Diarrhoea may be acute or chronic according to its underlying causes. 
The most common cause is spoilt food (dyspeptic diarrhoea). Catarrhal 
or ulcerative enteritis causes inflammatory diarrhoea. Dyspeptic and 
inflammatory diarrhoea are not to be confounded with the incontinence of 
fceces observed in the typhoid condition or in central nervous disease. 

Clinical Forms of Diarrhoea. — Dyspeptic diarrhoea in children from 
overfeeding or from spoilt food, erroneously attributed to teething (see 
Paediatrics); dyspeptic diarrhoea in adults; acute nervous diarrhoea; 
paroxysmal mucous colitis (membranous diarrhoea) ; chronic nervous 
diarrhoea (as in tabes) ; diarrhoea from catarrhal or ulcerative enteritis 
due to microbial infection, such as cholera asiatica, cholera infantum, 
typhoid, tuberculous, syphilitic, or dysenteric ulcerations; symptomatic 
(dyspeptic) diarrhoea in acute infectious disease, septic conditions, chronic 
malarial disease, cardiac, pulmonary, renal, pancreatic, or hepatic disease, 
etc.; fat diarrhoea in infants and adults in hepatic and pancreatic disease; 
amoebic diarrhoea (so called) in which amoebae are found in the stools; 
and morning diarrhoea, generally due to some organic ailment in the colon 
or rectum. 

General Treatment. — The symptomatic management of diarrhoea in 
adults is exceedingly simple. In the mild forms temporary dieting will suf- 
fice, and we can aid nature by administering a good dose of castor oil to 
eliminate retained putrescible material. The diet should consist of burnt 
flour gruel or slimy soup and some farinaceous water or toast water, mint 
tea, or carbonated water to quench thirst. Should the watery discharges 
continue, the peristaltic sedatives and astringents are indicated. Opium 
may be administered, five to ten drops of the tincture for adults, given 
once or twice, or tannin, gr. v to x, bismuth, gr. x to xx, several times a day. 

The return to the ordinary food must be gradual, and dilute HC1 may 
be given to aid digestion. In children and adults flushing of the colon 
may be practised once or twice a day. Abdominal pain may be controlled 
by opium and belladonna suppositories and by applying a moist compress 
or hot water bag to the abdomen. Chronic diarrhoea due to ulceration 
in the lower bowel may require the establishment of a fistula and flushing 
of the bowel from above downward. 



TYMPANITES AND DILATATION OF THE COLON 



287 



Diarrhoea secondary to other disease will be managed on the same lines, 
with due regard to the underlying conditions. 

Mucous Diarrhoea, Mucous Colic, Membranous Enteritis. — This ailment 
is looked upon as a neurosis, and it occurs mainly in women of a neuro- 
pathic constitution, particularly in women with large bellies (enteroptosis) 
and rarely in children. Its purely neurotic nature is doubtful because 
mucous colic is often associated with follicular inflammation in the lower 
intestine. It manifests itself by the usual gastrointestinal symptoms, 
great nervous irritability, and painful and paroxysmal passages of mucus 
and membranes from the bowel, the attacks lasting from three to seven 
days. The membranes may be shreddy, ribbon-shaped, cordlike, or cylin- 
drical. Emaciation and loss of strength occur in varying degrees, and 
numerous other conditions may coexist with this trouble. In making the 
diagnosis it is important to know that various substances may simulate 
membranes. 

Treatment. — Liberal mixed food, no liquid diet, out of door exercise, 
cold douches, wearing an abdominal supporter, the hot water bag to the 
abdomen to relieve pain, or an occasional suppository. Morphine injections 
should be given only in severe pain, as neurotics are apt to acquire the 
morphine habit. 

In the intervals between the attacks the patient is to receive every night, 
before going to bed, an enema of warm oil (ten to fifteen ounces), to be 
retained all night if possible. After the first week, the enema may be given 
every other night, and finally only once a week, until five to six months 
have elapsed. The patient should have a movement from the bowels 
every morning, and if necessary an enema of soap water may be given. 

Incontinence of Faeces may be produced by paralysis or destruction of 
the anal sphincter from whatever cause. Sometimes it results from deep 
ulceration, benign or malignant, but more frequently it is the result of 
operations in the lower rectum, especially for fistula, when the sphincter is 
cut obliquely instead of at right angle (Gant). 

Treatment. — We can cure but few cases, yet we are able to make most 
of these sufferers fairly comfortable, so much so that they can go about 
with their fellow men. This is accomplished by (a) plastic operation; (6) 
cauterization. 

Plastic operation for the relief of incontinence resembles the operation 
for the repair of a badly lacerated perinseum. The ends of the muscle must 
be located, freshened, and sutured together with catgut. The operation 
must be repeated until the desired result is obtained. 

Cauterization is best effected by deep burning of the mucosa in one or 
more places with the object of producing artificial stricture. The cauteriza- 
tions should be at least six weeks apart, and should be repeated until 
sufficient contraction occurs to prevent leakage. 

TYMPANITES AND DILATATION OF THE COLON 

Meteorism is associated with many forms of acute and chronic illness and 
may be defined as an inflation of the intestines with gases — the various gases 
which form in the intestines or are swallowed (air) and are absorbed into 



288 



THE DIGESTIVE SYSTEM 



the blood or find a ready or natural outlet by the mouth or the anus, pro- 
vided the muscular elements are in good tone. Increased gas production 
lessened absorption, and insufficient expelling power are the causative 
factors of meteorism found in dyspepsia, enteritis, intestinal indigestion, 
typhoid fever peritonitis, obstruction, constipation, hepatic derangements, 
lead colic, rickets, and hysteria. Tympanites may impede the action of 
the diaphragm and heart and cause pain, dyspnoea, and collapse. 

Symptoms. — The symptoms are distention, a tympanitic percussion 
sound, tenderness, and colic. 

In tympanites from perforation the liver dulness is obliterated. 

Treatment. — (a) Of the underlying cause; (6) Symptomatic. 

Turpentine internally, enemata, hot stupes, and hot peppermint tea 
may be employed, also charcoal, bismuth, hydrochloric acid, ether, opium, 
massage of the abdomen, vibratory massage, and the introduction of a 
rectal tube or puncture of the intestine. In prolonged tympanites an 
out of door life and cold sponge baths are indicated. In colic and tym- 
panites of children from too much milk, dilute the milk. In tympanites 
in typhoid fever, stop the use of milk. 

DILATATION OF THE BOWEL, CONGENITAL AND ACQUIRED 

Dilatation of the bowel may be due to obstruction of the bowel or 
chronic constipation and other causes, and in some instances no organic 
cause can be discovered (idiopathic dilatation). The distention of the 
abdomen and constipation are the most prominent features. The general 
health deteriorates. An autopsy in such cases reveals an enormous enlarge- 
ment of the transverse colon and sigmoid flexure. 

Prognosis. — The prognosis in these cases is unfavorable. Eighteen out 
of twenty-four cases reported are known to have terminated fatally. 

Treatment. — This includes tonic hygienic management, the selection 
of proper food, mild abdominal massage, vibratory massage, laxatives, 
enemata, or suppositories, and the use of a rectal tube to remove the gas. 
In cases which do not improve under such treatment an exploratory 
laparotomy may be indicated. 

ACUTE CATARRHAL ENTERITIS 

Acute catarrhal enteritis in adults occurs primarily or is secondary to 
various ailments, and should be looked upon as an infection or intoxication 
due to putrid intestinal contents, decomposed food, or some irritant poison. 
It is a common trouble in hot weather when food is apt to spoil. 

Symptoms. — These are diarrhoea, colicky pain, gurgling noises from 
gases, sometimes vomiting, a furred tongue, thirst, loss of appetite, scanty 
urine, and occasionally fever. The duration is from three to eight days. 

Prognosis. — The prognosis is favorable. In rare instances an apparently 
acute enteritis may develop into peritonitis with effusion, meteorism, and 
a rigid abdomen. Such cases are due to the perforation of a simple or tuber- 
culous ulceration of the intestine or to the breaking up of a degenerated mesen- 
teric gland, or an embolic thrombosis in some mesenteric vessel. 



ACUTE GASTROENTERITIS IN ADULTS; CHOLERA MORBUS 289 



Clinical Varieties. — Duodenitis is sometimes diagnosticated on account 
of the associated jaundice if the small intestine, jejunum and ileum, is the 
seat of inflammation. The stools are flocculent and contain undigested 
food, unchanged bile, and some mucus. 

Colitis is characterized by marked pain, diarrhoea, tenderness over the 
colon, and souplike stools. 

In proctitis, or rectal catarrh, there is painful tenesmus with mucus and 
pus in the discharges. 

Treatment. — Rest in bed, evacuation of the bowels by castor oil (5j) 
or a saline cathartic. 

Bland Diet. — Burnt flour soup, slimy soup, Vichy, tea, toast' pepper- 
mint tea with tropon, raw eggs. 

Medication. — Give five drops of dilute hydrochloric acid in water after 
eating. To stop pain, give from five to ten drops of laudanum. To check 
persistent diarrhoea, order ten grains of tannin or tannigen, with or without 
half a grain of opium, or this prescription: 



M. S.: One such powder twice a day. 

To aid nature in eliminating foul material, we employ flushing of the 
bowels once or twice a day. (See General Therapeutics.) 

ACUTE GASTROENTERITIS IN ADULTS; CHOLERA MORBUS 

This is a common disorder in hot weather, and is to be classed as an 
infection or intoxication due to putrid or poisonous gastrointestinal contents 
and spoilt food and drink, such as canned goods, fish, shell fish, ice cream, 
milk, etc. 

Symptoms. — The symptoms are the same as in acute enteritis, but in 
addition there is vomiting on account of the participation of the stomach. 

Treatment. — As the physician is generally called after vomiting has 
set in, an emetic is seldom necessary. In some cases stomach washing will 
be indicated. The patient should rest in a cool room with an ice bag to 
the head, should have ice to quench thirst and subdue nausea and vomiting, 
and should not partake of food for the time being. Internally we give: 



Aquae amygd. amar., ) 
M. S.: Fifteen drops, in ice. cold carbonated water, every hour 
until relieved. 

Lavage of the bowel will aid nature in eliminating foul material. 

Diet. — For the first and second days the diet will be the bland one 
mentioned above. When the patient is fully convalescent, he can return 
to the ordinary food. 

Prognosis. — The prognosis is favorable except in old and feeble people 
and infants, who sometimes die in collapse. 



R, Bismuth, subnitrat., 
Pulv. opii, 



gr. xx ; 
gr. ss. 




290 



THE DIGESTIVE SYSTEM 



CHRONIC ENTERITIS 

This is usually a sequel of repeated attacks of acute enteritis or dysen- 
tery, but it may develop in consequence of obstruction to the portal 
circulation in chronic hepatic or cardiac disease and chronic malarial 
disease, etc. 

Symptoms. — Diarrhoea is present, or diarrhoea alternating with constipa- 
tion. The pain is not so severe as in the acute form. Mucus and undigested 
food are passed in the stools. 

Differential Points. — An ailment running a course as a chronic enteritis 
may have for its underlying cause syphilis, tuberculous ulceration of the 
intestine, or tuberculosis of the peritonaeum. A careful clinical investiga- 
tion will finally locate the trouble. This involves, besides the usual inquiries, 
an examination of the stools, an examination per rectum, a record of the 
temperature for two weeks, and an examination of the blood. 

Treatment. — The underlying cause must be treated in the first place. 
Rest in bed, a bland restricted diet (including gum arabic mucilage), and 
intestinal flushing are indicated. In malarial subjects quinine must be 
used; in syphilitic subjects, antisyphilitic treatment is indicated; in tuber- 
culous subjects, an out of door life is demanded. When tuberculosis of 
the peritonaeum is suspected, an exploratory laparotomy may furnish us a 
positive diagnosis and afford relief and cure to the patient if the tuberculous 
infection is not a general one. The symptomatic medication in chronic en- 
teritis is with bismuth, tannin, and opium. If a local examination should 
show accessible ulceration in the lower intestine, local applications of silver 
nitrate are useful, followed by extract of opium (gr. ss) and extract of bel- 
ladonna (gr. ss) suppositories. In otherwise incurable cases the intestine 
may be flushed from above downward by establishing a fistulous opening 
in the right flank. 

DYSENTERY IN ADULTS 

When an infection is localized in the lower bowel and is intense enough 
to produce much local inflammation, diarrhoea, fever, tenesmus with mucus, 
blood, and the passage of fibrinous membranes, we speak of membranous 
enteritis, or dysentery, which may occur sporadically or in epidemics. As 
dysentery is transmissible like typhoid fever, the patient should be isolated 
and the stools disinfected with lime or copperas. 

Clinical Varieties. — 1. Catarrhal dysentery. Duration about one week. 

2. Amoebic, or tropical, dysentery. The amoebae are found in the 
stools and there is a steady loss of strength and weight. Uncomplicated 
cases last from six to twelve weeks, with a tendency to become chronic 
and with hepatic abscess following. 

3. Chronic dysentery. Distinguished from other forms of chronic 
diarrhoea by the tenesmus and bloody, mucoid stools. 

Prognosis. — In the mild forms, recovery is the rule. The mortality 
varies according to the nature of the lesion and the vitality of the sufferer. 

Treatment. — Rest in bed, a bland diet (see Diarrhoea), flushing of the 
bowels, simple and medicated, suppositories of extract of opium, gr. ^, to 
overcome pain and tenesmus, astringent medication. 



INTESTINAL ULCER 



291 



The treatment and diet are practically the same as in catarrhal enteritis, 
but the local management is more energetic. Irrigation of the bowels must 
be practised two or three times a day. For irrigating we use boiled water, 
aromatic water (mint decoction), starch water, with or without opium, 
tannin water (5 to 1,000), alum water (5 to 1,000), ichthyol water, 1 per 
cent, or nitrate of silver solution, 5j to a quart. 

Quinine in watery solution, 1 to 1,000, is employed in amoebic dysentery. 
Astringent internal medication is not to be used in the acute stage, but is 
efficacious in the convalescent stage. 

Bismuth subnitrat., gr. x to xxx, may be given three times a day, or 
tannin, gr. v to x, at the same intervals. 

Py Plumb, acet., gr. iij; 

Pulv. opii. gr. ss. 

Such a powder to be given three times a day. In some cases a daily 
dose of half an ounce of castor oil with ten drops of tincture of opium is fol- 
lowed by a cure. 

INTESTINAL ULCER 

Causes. — Ulceration in the intestines may result from a variety of 
causes, viz. : Injury, ulceration in enteritis, acute and chronic, in tuberculosis, 




Fig. 110. — Tuberculous Ulcer of the Ileum. (Nicoll, Archives of Paediatrics.) 

in syphilis, in cancer, in typhoid fever (see Typhoid Fever), in thrombosis 
and embolism in heart disease and pyaemia, in stercoral ulcers from the 
pressure of hard faecal masses, and by pressure and perforation from without 
inward. Duodenal ulcers have been observed in infants and adults. 

Symptoms. — Diarrhoea, bloody and tarry stools, pus and tissue, shreds 
in stools, colicky pain, and perforative peritonitis. 
20 



292 



THE DIGESTIVE SYSTEM 



Diagnosis. — The differential diagnosis involves a lucid anamnesis and 
painstaking examination of the stools and of the lower intestine by means 
of the Kelly tube, if necessary under narcosis. 

Prognosis. — The prognosis depends upon the underlying cause. 

Treatment. — The treatment is specific, surgical, or palliative, according 
to the underlying condition. The diet, hygiene, and internal and local 
medication are discussed under Diarrhoea and Enteritis. The specific treat- 
ment involves an inunction cure (mercurial ointment) or mercury and iodide 
of potassium internally. The surgical treatment involves flushing of the 
bowel through a fistula established in the colon on the right or left side. 

TUBERCULOSIS OF THE INTESTINE 

This may be primary, but is usually secondary to pulmonary tuberculosis. 
As such, it is a fatal complication for which there is only palliative or 
symptomatic management. 

APPENDICITIS 

Diagnostic Palpation of the Appendix Vermiformis 

In searching for the appendix the author adheres to the rules laid 
down by Dr. G. M. Edebohls, of New York, as follows: 

"The examiner, standing at the patient's right, begins the search for 
the appendix by applying two, three, or four fingers of his right hand, 
palmar surface downward, almost flat upon the abdomen, at or near the 
umbilicus. While now he draws the examining fingers over the abdomen 
in a straight line from the umbilicus to the anterior superior spine of the 
right ilium, he notices successively the character of the various structures 
as they come beneath and escape from the fingers passing over them. 
In doing this the pressure exerted must be deep enough to recognize distinctly, 
along the whole route traversed by the examining fingers, the resistant surfaces 
of the posterior abdominal wall and of the pelvic brim. Only in this way 
can we positively feel the normal or the slightly enlarged appendix; pressure 
short of this must necessarily fail. 

" Palpation with pressure short of reaching the posterior wall fails 
to give us any information of value; the soft and yielding structures simply 
glide away from the approaching finger. When, however, these same struc- 
tures are compressed between the posterior abdominal wall and the examin- 
ing fingers, they are recognized with a fair degree of distinctness. Pressure 
deep enough to recognize distinctly the posterior abdominal wall, the pelvic brim, 
and the structures lying between them and the examining finger forms the 
whole secret of success in the practice of palpation of the vermiform appendix. 

" Proceeding in this manner, the appendix is recognized as a more or 
less flattened, ribbon-shaped structure when quite normal, or as a more 
or less rounded and firm organ, of varying diameter, when its walls have 
been thickened by past or present inflammation. When it is the seat 
of inflammatory changes, the appendix vermiformis is always more or less 
sensitive on pressure; the normal appendix exhibits no special sensitive- 
ness on being squeezed. 

"There are two useful landmarks in practising palpation of the vermi- 



APPENDICITIS 



293 



form appendix : McBurney's point and the line of the right iliac arteries. 
The origin of the appendix from the caecum, whatever course its continuation 
may run, is almost uniformly at McBurney's point; hence the diagnostic 
value in appendicitis of pressure over this point. The iliac arteries are 
useful in a twofold way: firstly, because to feel their pulsation distinctly 
means that the fingers have reached the posterior abdominal wall; and 
secondly, because the normal appendix is very constantly found about a 
finger's breadth outside of the artery, on a line between the umbilicus 
and the anterior superior spine of the right ilium. 

"A good guide in searching for the appendix is formed by the right 
common and external iliac arteries, the pulsation of which can be easily 
and plainly felt. The line of these vessels corresponds to a surface line 
drawn from the left of the umbilicus to the middle of Poupart's ligament. 
The appendix is generally found almost immediately outside of these 
vessels. At its base it is separated from the vessels by a space of from 
one half to one inch, while lower down in its course it generally crosses very 
obliquely the line of the arteries. 

"Theoretically, two conditions mainly militate against the successful 
palpation of the appendix vermiformis after the method above described; 
practically, the difficulties offered by these two conditions amount to very 
little or nothing. I refer to the variable location of the appendix and to 
the fact of its common deep situation behind the caecum. 

" With the very rare exceptions of its situation far away from its usual 
site, the origin of the appendix vermiformis is practically always found at 
what is known as McBurney's point. In fact, it is this constancy of the 
situation of the appendix which gives its practical value to McBurney's 
point in the diagnosis of appendicitis. The tenderness elicited by extremely 
localized pressure at McBurney's point is due to the presence beneath the 
finger of the inflamed appendix." 

Definition and Varieties. — Appendicitis is a disease of the vermiform 
appendix with catarrhal, ulcerative, perforative, and gangrenous stages. 
The clinical varieties are the acute cases and the chronic recurrent cases. 
Infection, tumefaction, and various degrees of strangulation of the appen- 
dicular blind sac appear to be the pathological explanation of appendicitis. 
In some families there is an hereditary predisposition to appendicitis. 
Edebohls maintains that chronic appendicitis is the chief symptom and 
most important complication of movable right kidney. 

Symptoms of Acute Appendicitis. — Acute pain in the right lower abdo- 
men which may radiate in various directions ; pronounced tenderness in the 
right iliac fossa. McBurney's point (the centre of a line drawn from the 
anterior superior spinous process to the navel), pronounced tenderness of 
the appendix as elicited by palpation, nausea, vomiting, fever, accelerated 
pulse. Diarrhoea or constipation may be present. Leucocytosis is a fairly 
constant symptom. Suppuration is provable by an exacerbation of previous 
symptoms and increase in size of the tumor or swelling located at 
McBurney's point or in the lumbar region or elsewhere. Perforation of the 
appendix may be indicated by severe pain, great tenderness, and marked 
rigidity. Pronounced sepsis may be inferred from vomiting and rapid 
pulse and high fever. 



294 



THE DIGESTIVE SYSTEM 



Differential Points. — In renal colic and twists of the ureter the pain 
radiates into the groin and testicle, and there is hsematuria or hsemo- 
globinuria. Pain in the groin and testicle is sometimes observed in appen- 
dicitis. The urine should be examined for small calculi. 

Indigestion and Enterocolitis. — No circumscribed tenderness. No rigidity. 
No tumor. No tenderness of the appendix on palpation. 

Intestinal Obstruction. — Palpation of the appendix is negative. 

Acute Cholecystitis or Hepatic Abscess. — Tenderness on pressure from 
below the, margin of the ribs upward. No tenderness of the appendix on 
palpation. 

Gallstone Colic— Pain radiates to the back on the right side, and the 
appendix is free on palpation. 

Salpingitis, oophoritis, and ectopic gestation are recognized by bimanual 
palpation of the pelvic organs, and the latter is denoted by menstrual 
irregularities. 

Perinephritic abscess on the right side may arise from appendicitis, 
but is usually a complication following an operation for appendicitis. If 
it is independent of appendicitis, the appendix is not tender on touch. 

Tuberculous peritonitis is a slow process; palpation of the appendix 
may be impossible. 

Mucous colic gives its own characteristic symptoms, and the appendix 
is found to be free on palpation. 

Coxitis. — In young children appendicitis has been mistaken for hip 
joint disease. As the appendix can readily be palpated in children, the 
differential diagnosis is not difficult. 

Acute rheumatic myositis of the rectus abdominis muscle simulates appen- 
dicitis. 

Typhoid fever is usually associated with right iliac tenderness. The 
Widal serum test will settle the diagnosis in most cases. In typhoid fever 
the onset is slow and roseola is generally observed. Seibert, of New York, 
has reported two cases of typhoid fever combined with appendicitis. 

Influenza, pleurisy, pneumonia, malarial disease, herpes zoster of the 
twelfth intercostal nerve, and other infections which frequently begin with 
severe gastrointestinal symptoms cannot be mistaken for appendicitis 
by any one who has learned to palpate the appendix. 

The prognosis is uncertain. Mild cases end in recovery, as do localized 
abscesses after an operation. Severe septic peritonitis cases will often 
prove fatal with or without an operation. We are unable to judge of the 
clinical severity of a case before an operation, and we are unable to give a 
reliable prognosis, and physician and surgeon therefore should co-operate 
in the management of a case. 

Treatment. — General Indications for Operation: 

1. In cases of diffuse perforative appendicitis an immediate operation is 
indicated. Exceptionally patients get well without an operation. 

2. In cases of acute appendicitis the patients always need careful observa- 
tion. If the pulse has the tendency to stay high, the indication for an oper- 
ation is given. 

3. In mild cases, when the patients are doing well, wait for the sub- 
sidence of symptoms and operate in the interval. 



BENIGN AND MALIGNANT NEOPLASMS OF THE INTESTINE 295 



4. In case of doubt, the operation is better than waiting. After the 
first attack from which the patient recovers without an immediate operation 
the appendix should be removed. The appendix, once inflamed, must be 
looked upon as a diseased organ which is very apt to give repeated and 
more serious, even fatal trouble in the future. Chronic appendicitis is 
to be diagnosticated, not on subjective symptoms, but on objective signs. 
Unless, in cases of suspected chronic appendicitis, the surgeon can recognize 
by palpation the thickened appendix and limit tenderness on pressure to 
the diseased organ, he will not be justified in operating. One broad rule 
governing the question of operative interference in appendicitis should be, 
not to operate in chronic cases unless you can feel the diseased appendix, 
nor in acute cases unless by palpation you can recognize either the diseased 
appendix or the presence of a tumor. Anaesthesia may be necessary, in 
exceptional instances, to decide the question. 

The gravest complications following appendicitis are septic peritonitis 
and septic thrombosis of the portal vein. The latter is almost invariably 
fatal and may be recognized by fever, chills, sweating, rapid action of the 
heart, and local tenderness. 

Non-operative Treatment. — If in a given case of appendicitis an 
immediate operation is not decided upon, the management is symptomatic, 
as follows: Rest in bed, an ice bag or hot water bag to the abdomen, liquid 
diet, a small enema of warm soap water or oil each day or castor oil in- 
ternally, and, to aid digestion, 5 to 10 drops of dilute hydrochloric acid, to 
be given in water after each feeding. It is not wise to mask the clinical 
picture by giving morphine or opium. When pus formation is evident, and 
an operation has been decided upon, the patient can be made comfortable 
by morphine subcutaneously. When the pain is quite severe and the pulse 
and temperature are not high, and it has been decided not to operate 
during the first attack, an injection of morphine may also be indicated. 

BENIGN AND MALIGNANT NEOPLASMS OF THE INTESTINE 

Diagnosis. — The diagnosis of carcinoma rests on the following points: 
The age of the patient, usually over fifty years, a palpable tumor, progressive 
anaemia and cachexia, signs of obstruction or disturbed bowel action, 
colicky pain and vomiting, the presence of blood, pus, and shreds in the 
stools, secondary deposits in the liver, lungs, and mammae, and such other 
symptoms as may be inferred when the kidney or ureters are involved or 
perforation, fistulae, and general peritonitis are present. 

Differential Points. — Carcinoma of the rectum may be mistaken for 
chronic dysentery or non-malignant stricture, and vice versa. A tumor 
due to f cecal impaction can be indented. Cysts and tuberculosis of the peri- 
tonaeum or mesentery may simulate a cancerous tumor. Movable kidney 
and chronic appendicitis have been taken for cancer of the intestine. 
Cancer of the pancreas, of the pylorus, and of the gall bladder may simulate 
cancer of the intestine. Benign tumors have been observed and mistaken 
for cancer of the intestine. In all such obscure conditions the proper 
procedure is exploratory laparotomy with immediate extirpation and 
intestinal anastomosis if feasible. If the case is found to be "inoperable " 
x ray treatment is indicated. 



296 



THE DIGESTIVE SYSTEM 



INTESTINAL OBSTRUCTION, ACUTE AND CHRONIC 

Symptoms. — The cardinal symptoms of intestinal obstruction are acute 
and severe pain (sometimes absent), no movement or passage of flatus 
from the bowels, vomiting (gastric, bilious, or faecal), tympanitic distention 
of the abdomen, usually no fever, prostration and collapse in the termi- 
nal stage. 

The Site of the Obstruction. — If the obstruction is high up, there is 
less abdominal distention than in obstruction of the colon; if in the lower 
bowel, there may be tenesmus and the passage of bloody mucus. Abdominal 
palpation and bimanual palpation externally and through rectum or vagina 
may reveal a tumor or swelling. On various occasions the writer has 
been able to detect the site of the obstruction by noting where the tympa- 
nitic percussion sound of distended intestine merged into dulness over a 
collapsed area of intestine. 

Invagination, or intussusception, of the intestine may be ileocecal, ileo- 
colic, or colicorectal. In infants and young adults the onset is more or 
less acute, with tenesmus, mucus, and blood. Occasionally a sausage- 
shaped tumor can be felt. 

Differential Points. — Volvulus, or twist of an intestine, is usually located 
in the large intestine or the sigmoid flexure, and gives no distinctive symp- 
toms apart from those already enumerated. 

Foscal obstruction is usually chronic, with a history of constipation. 
Indentible fsecal masses can sometimes be felt. 

Strangulation is usually through adhesions and narrow natural slits 
(foramen of Winslow, diaphragmatic hernia, and incarcerated hernia). 
A palpable tumor is rare in cases of strangulation. 

Gallstone obstruction of the intestine is usually intermittent. 

Stricture of the intestine from tdceration is seldom recognized before 
opening the abdomen, unless it is situated in the anal region. 

Stricture of the intestine from a malignant or benign tumor cannot be 
recognized in a tympanitic abdomen. 

Paresis of the intestine and obstruction sometimes follow abdominal 
section or peritonitis, and has been observed in neurotic constipated 
children. On auscultation the intestinal sounds are absent. Other rare 
causes of obstruction can only be conjectured. 

In enteritis and diffuse peritonitis with obstruction there is generally 
a rise of temperature. 

In hepatic colic and obstruction the pain is localized and characteristic, 
and jaundice is often present. 

In renal colic and obstruction the urine shows hsematuria or hsemoglobi- 
nuria. 

Treatment. — The treatment of bowel obstruction is by high enemata 
and inflation, in the dorsal or knee-elbow or inverted position, by means 
of soap water (soft rectal tube) ; oil with the soft rectal tube; air with the 
soft catheter, bicycle pump, or hand bellows, or carbonic acid gas (inverted 
siphon). 

The best guide to the amount which has been introduced is tension of 
the abdominal walls. A thorough trial should occupy fifteen to thirty 



REMARKS ON STRANGULATED HERNIA AND TAXIS 



297 



minutes, and it may be repeated in an hour. It may be done under narcosis. 
Gentle manipulation through the abdominal wall is permissible. 

If after two or three trials there is no improvement, an operation should 
not be delayed for more than three or four hours. In cases not acute, where 
several days have passed without symptoms of strangulation, laparotomy 
may be delayed longer and further attempts at reduction are proper. The 
writer has observed paretic and pronounced obstipation in a girl of nine 
years, lasting eleven days, with complete recovery. In ileus injections of 
atropine sulphate may be tried. 

Cathartics are contraindicated as soon as the diagnosis of complete 
obstruction is made. Opium or morphine may be administered, to quiet 
pain. 

HEMORRHAGE FROM THE INTESTINES 

Causes. — Haemorrhage from the intestines may result from a variety 
of causes, such as dysentery, typhoid ulcer, malignant disease, the haemor- 
rhagic diathesis, acute and chronic, congestion in the portal circulation, 
a foreign body, simple ulcer, tuberculous or syphilitic ulcer, aneurysm, 
haemorrhoids, vicarious menstruation, haemorrhage from above the intestine, 
and swallowed blood. In bleeding from the intestines all these possi- 
bilities must be borne in mind, an exact diagnosis being arrived at by 
exclusion. 

Treatment. — Rest, fluid diet, opium and acetate of lead internally, 
an ice bag to the abdomen, strychnine, and suprarenal extract. Haemor- 
rhage of the lower intestine may be controlled to a certain extent by means 
of clysmata of cold water, 1 quart; or alum water, 3ij ad Oij; or tannin 
in water, 5j ad Oij; or by means of a tampon or the actual cautery. 

REMARKS ON STRANGULATED HERNIA AND TAXIS 

Definition. — An incarcerated hernia is one in which the bowel contents 
cannot escape, but in which the blood circulation is not cut off. A strangu- 
lated hernia is one in which the constriction is sufficient to shut off the 
circulation of the blood. 

Symptoms. — The symptoms are the logical result of the conditions pro- 
ducing them and are sufficiently characteristic to allow us to form a diagnosis 
by a discrimination between functional constipation and abdominal shock 
with obstruction. 

Pain. This comes suddenly, is severe, is at first localized, and becomes 
general over the abdomen. Sudden cessation of local pain without re- 
duction of the hernia is a grave indication of gangrene. 

Obstipation is pronounced throughout, but the lower bowel may empty 
itself, after which there will be no passage of gas or faeces. 

Tympanites will increase until relief is offered. 

Vomiting is early and persistent and eventually becomes stercoraceous. 

The pulse is accelerated and becomes irregular, small, and thready. 

The temperature may be subnormal in shock and collapse, and may be 
elevated from systemic intoxication. 

The local symptoms are those of inflammation — swelling, heat, redness, 
pain, and tenderness. The face is pinched, drawn, and anxious. 



298 



THE DIGESTIVE SYSTEM 



Treatment. — The treatment for strangulated hernia is by operation. 
Before we cut down upon the strangulating structures it may be justifiable 




Fig. 111. — Represents a Properly Applied Truss for the Retension 
of Double Inguinal Hernia. 

The frame is of German silver covered by hard rubber, with pads of the latter substance. 



to place the patient in a position which may favor spontaneous reduction 
and apply an ice poultice to the seat of the trouble, and to employ gentle 
taxis with or without anaesthesia, with the hope of reducing the hernia. 
Failing in this after one or two trials, the use of the knife is indicated. 

To wait for fsecal vomiting or until the patient 
is exhausted is inexcusable. 

Clinical Varieties. — Inguinal hernia (com- 
plete or incomplete), femoral hernia, umbilical 
hernia, ventral hernia, congenital hernia, dia- 
phragmatic and other internal hernias. 

Regarding the question, "Does hernia 
exist? " it may be safely stated that reducible 
tumors in the region where hernias are found 
are generally hernia. 

Dr. W. B. Degarmo's definition of a good 
truss: A well fitting truss is one which retains 
the protruding viscera within the abdomen and 
has its springs so shaped to the body that it 
will remain constantly in place no matter what 
position the body assumes. 




INTESTINAL PARASITES 

Common Forms. — The cylindrical worm 
\Ascaris lumbricoides) , the thread worm (Ox- 
yuris vermicularis) , the tapeworm (Taenia 
saginata or mediocanellata, the beef tapeworm, sucking disks without 
hooklets; Taenia solium, pork tapeworm. The head has hooklets). 



Fig. 112. — Skein of 
Worsted Truss. 



INTESTINAL PARASITES 



299 



Those species of worm are found in the adult as well as in the child. 
In America we generally see the beef tapeworm. The Taenia solium is the 
common tapeworm of Europe. When the mature proglottides are eaten 
by cattle, the ova wander into various tissues and become encysted as 
cysticerci. 

Treatment. — The cylindrical worm is driven out by the administration 
of santonin, gr. j to ij, ter in die, and saline laxatives. 

The thread worm is removed by enemata of garlic boiled in milk. 

The tapeworm in man flourishes in the small intestine, and the only 
certain indication of its existence is the passage of links or sections with 
the stools. Give a saline laxative twenty-four hours before giving the 
following remedy: 

No. 1. 

R Oleoresin of male fern, 5iij; 

Ext. kamala; fl., 3ij; 

Chloroform, gtt. x; 

Croton oil, gtt. ij ; 

Castor oil, qs. ad, §ij. 

M. S.: Give in two doses, one half at 7, the remainder at 9 a. m. 

The patient should eat little between the saline and the remedy. 

Or give No. 2. 

1$ Pelletierine tannate, gr. jv; 

Oleoresin of male fern, ^xxx; 

Chloroform, Trj, V ; 

Syrup, = §j. 

M. S. : Take in one dose after a saline laxative, fasting in the 
mean time. 

Give a tablespoonful of castor oil two hours after the remedy has been 
taken. 

Should the worm not be expelled, the remedy can be given a second 
trial after a week of preliminary medication, as follows: 

R 1 Spt. terebinth., 



Tinct. valerian seth., 



aa, oij- 



M. S. : Ten drops on sugar four times a day. 

During this week the patient should frequently eat pumpkin seed and 
herring salad, also strawberries if they are in season. 

A good tapeworm remedy in capsules is for sale in the shops under the 
name of Dietrich's tapeworm remedy. 

Rare Forms : Ankylostomiasis Hook Worm Disease. — Dr. R. T. Hewlett, 
in the Practitioner for November, 1904, writes: 

"Ankylostomiasis, the condition resulting from the presence of the 
intestinal worm, the Ankylostomum , or, as it is now termed, the Uncinaria, 
is a disease of very wide distribution, occurring over something like three 
fifths of the habitable globe. Attention has recently been specially directed 
to it from its occurrence in the Dalcoath Mine, Cornwall. In America it is 
widely spread, but the parasite here, the Uncinaria americana (Stiles), 



300 



THE DIGESTIVE SYSTEM 



is a different species from that of the old world. The chief difference 
between the U. duodenalis and the U . americana are the replacement of 
two of the ventral recurved clawlike hooks of the buccal orifice of the former 
by a pair of semilunar plates, and by the egg of the latter being larger than 
that of the former. The larvae, which develop in mud from the ova voided 
in the excreta, enter the body either by the mouth or through the skin 
without perceptible lesion. From the skin they pass into the lymph or 
blood vessels, are swept into the general circulation, and eventually reach 
the lungs, whence they pass from the blood vessels into the pulmonary 
alveoli. From the time the larvae perforate the skin until they reach the 
lungs, they remain of the same size; but as soon as they reach the air 
vesicles they begin to grow rapidly. They pass into the bronchioles, up 
the bronchi and trachea, and, emerging through the glottis, pass down the 
oesophagus to the duodenum, where they become sexually mature. In 
order, therefore, to prevent infection, it is necessary, not only to safeguard 
the food, but also to protect the bare skin. 

" The drugs of value in the treatment of ankylostomiasis are thymol and 
male fern. According to Lutz, 'after a light meal at 11 a.m., give calomel, 
0.5 gramme, and powdered senna, 2 grammes, divided into four doses, one 
hour apart. The last dose may be omitted if sufficient action is secured 
by the three others, and if the full amount does not accomplish its end, 
more senna should be given; after this nutritious and easily digested liquid 
food is the proper diet. This insures liquid evacuations, after which thymol 
is given in 5 to 15 grain doses, in capsule, at intervals of four hours, until 
four capsules are taken, after which a dose of Epsom salts is given." 

Anguillula intestinalis is the name of a parasite found in the stools in 
cases of colicky diarrhcea of the Asiatic zone. In the treatment, thymol and 
male fern are advised to be given internally. 

Amoeba Intestinalis. — (See also Amoebic Diarrhoea.) 

1. The intestine of man may be infected with two varieties of amcebas, 
one pathogenic (Entamoeba dysenteries) , and the other non-pathogenic (En- 
tamoeba coli). 

2. Entamoeba coli, the non-pathogenic variety, is found in 65 per cent of 
the healthy individuals studied, and in 50 per cent of individuals suffering from 
diseases other than dysentery, if a saline cathartic has been administered. 

3. These organisms can be easily distinguished in both fresh and 
stained specimens. 

4. They differ widely in their method of reproduction, and this is the 
most important method of distinguishing them. — 0. F. Craig, M.D. 

ENTEROPTOSIS; SPLANCHNOPTOSIS; GLENARD'S DISEASE 

Definition. — A general term applied to a falling or dropping of the 
abdominal viscera due to inherent or acquired weakness of the tissues. 

C. Schwerdt, of Gotha, Germany, has reported ninety-five cases (eighty- 
nine in women, six in men). In sixty-nine cases the stomach was dis- 
placed (?) or atonic; in eighty-six cases the right kidney was movable. 
The liver and spleen play but a rare part in this condition. 

Clinical Features. — The clinical features of enteroptosis are a sense of 
fulness in the epigastrium, nausea, eructations, vomiting, obstinate con- 



INTESTINAL PUTREFACTION AND TOXAEMIA 



301 



stipation, abdominal distention, and colic, and in more marked cases pain 
in the back and polyuria, and often in cases yet further advanced pain in 
the diaphragm, palpitation, dyspnoea, sleeplessness, mental depression, 
and melancholia — a clinical picture so often spoken of as " purely functional " 
or "neurasthenic," but which may be referred, with some show of reason, 
to a condition of "anatomical changes " existing and demonstrable. 

The essential element productive of this dislocation is possibly a lessened 
intraabdominal pressure which has its origin in a lax, atonic anterior ab- 
dominal wall. Such a condition exposes the hollow organs, otherwise 
supported, to the influence of gravity 
when filled with their normal contents, 
and one part after the other tends to 
fall, pulling other parts with it. 

The essence of the disease is to be 
sought for in the atonic and enervated 
condition of the nervous system. Pre- 
disposing factors are heredity, methods 
of living, all chronic diseases, the corset, 
and insufficient care during pregnancy 
and after. From this the conclusion is 
drawn that it is purely a constitutional 
disease. The anatomist, the patholog- 
ical anatomist, and the clinician are, 
unfortunately, not in accord in deter- 
mining what is normal and what is 
pathological in the position of various 
abdominal organs, and particularly the 
stomach. 

Treatment. — The wearing of a well 
fitting plain abdominal support (without 

special pads for the support of special organs) is the proper treatment for 
enteroptosis. Regulation of the bowels and the cool douche to overcome 
"nervousness " give satisfactory results. In some instances it will be nec- 
essary to fasten a wandering kidney, which may be the source of annoying 
reflex symptoms. Dr. A. Rose improvises an adhesive plaster support for 
enteroptosis. 




Fig. 113. — Abdominal Support, Plas- 
ter and Webbing (Dr. B. Schmitz). 



INTESTINAL PUTREFACTION AND TOXEMIA; AUTOINFECTION FROM 
THE INTESTINES; INTESTINAL ANTISEPSIS 

When fermentative changes in the gastrointestinal tract proceed beyond 
a certain point, they become a menace to comfort 'and health. Some 
persons experience little discomfort; others suffer severely. 

Amylaceous Fermentative Dyspepsia produces acetic, lactic, butyric, and 
other acids and carbonic acid and other gases, giving rise to distention, pain, 
soreness of the abdomen, acid urine, divers neuralgias, hemicrania, and inter- 
costal neuralgia, with and without constipation or diarrhoea, vertigo, etc. 

Putrid Proteid Fermentation produces sulphuretted hydrogen, carbonic 
acid gas, and aromatic bodies, such as indol, skatol, and ptomaines or toxines, 



302 



THE DIGESTIVE SYSTEM 



giving rise to malaise, fever, nervous depression, sleeplessness, melancholia, 
headache, vertigo, hemicrania, anorexia, or urticaria. 

The gases formed provoke pain by distention, and the organic acids 
interfere with normal digestion and irritate the mucosa of the intestine 
(catarrhal inflammation of the intestine in children who eat too much 
candy). 

The gases in both varieties may cause dyspnoea and suggest heart lesions 
and asthma (asthma dyspepticum). 

Intestinal putrefaction in infants may give rise to very high temperatures 
and convulsions, and an early recognition is of prime importance. In 
renal, hepatic, and cardiac disease intestinal fermentation is a serious 
complication, and the great value of laxatives is obvious. Undue intestinal 
fermentation is also seen in anaemia, chlorosis, and leucaemia — in fact, 
anaemia and haemorrhagic phenomena may result from intestinal fermenta- 
tion. Epileptoid seizures and possibly chorea are caused by intestinal 
indigestion. In the present state of our knowledge scurvy must be looked 
upon as a chronic ptomaine poisoning from prolonged intestinal putrefaction. 
In all such cases the ethereal sulphates are found in the urine. As a prac- 
tical test, the test for indoxyl in the urine is here given: Mix equal quantities 
of urine and strong HC1. Add a drop or two of freshly prepared chlorinated 
lime and a small quantity of chloroform, and shake. The indoxyl present 
will be converted into indigo blue by the chlorinated lime and show a blue 
color in the layer of chloroform. This is of value as a chemical test. 

Management of Intestinal Fermentation. — Sufferers from autoinfection 
must take only perfectly sound food and such articles as are least apt to 
become the source of putrid fermentation within the intestines. Persons 
who are liable to "bilious attacks " and attacks of "sick headache " or 
dyspeptic vertigo must be careful in indulging in the pleasures of the table, 
and avoid late dinners with wine and rich food. Children should not be 
allowed to have much cake or candy, and must avoid unripe or overripe 
and spoilt fruit. The management of indigestion in infants is discussed in 
the psediatric section of this book. 

Diet in Intestinal Indigestion. — No inflexible rule of diet can be 
given. Fresh bread, sweets, rich pastry, leguminous foods, cabbage, dense 
cheese, mayonnaise, beer, and sweet drinks increase flatulence and must be 
avoided. Milk is well borne by some and not by others. Stewed fruit is 
usually well tolerated. Smoking may have to be stopped for a time. In 
some instances a change to a vegetarian diet is followed by marked 
improvement. 

Exercise is a desideratum, such as walking, bicycling, rowing, riding, 
exercise with the punching bag, and gymnastics. 

Baths. — A cool sponge bath is always beneficial. 

Medication. — There is always marked improvement following free 
catharsis. Adults may take: 



Py Podophyllin., 
Calomel., .... 
Pulv. aromat 
Sacchar., . . . , 



gr. t ' 

gr. x; 

gr- ij; 

gr. x. 



M. S.: For one dose. 



INTESTINAL PUTREFACTION AND TOXAEMIA 



303 



On the following day five drops of dilute HC1 in water may be given after 
each meal. When there is a tendency to constipation, a "lapactic" pill 
at night, or a teaspoonful of Carlsbad salt each morning in a cup of hot water 
will help. 

Abdominal massage is beneficial. Hot water or hot peppermint tea 
once a day is also helpful. 
Children may take: 

1^ Calomel., gr. j; 

Sacchar., gr. x. 

M. S.: One such powder every hour until six are taken. 

Or we may order castor oil or citrate of magnesia or rhubarb and magne- 
sia, followed by two drops of dilute HC1 in a teaspoonful of essence of pep- 
sine after eating. Infants should receive no breast or bottle milk for six 
to eight hours, and should have farinaceous water instead of sterilized 
milk in hot weather. 

Enteroclysis is helpful in intestinal indigestion in adults and children. 
Irrigation of the colon is a simple and valuable procedure. 

Intestinal antiseptics of the salol and naphthol group are in the market 
by the score. The best antiseptic for the bowel is its own action, and the 
writer has been more successful in the management of indigestion on the 
lines laid down than by the administration of the modern coal tar derivatives. 
In gastrointestinal fermentation, and in indigestion secondary to cardiac, 
renal, and hepatic disease or acute infectious disease, we administer pepper- 
mint tea or dilute HC1 after each meal, or 

1$ Tinct. iodini, gtt. x to xx; 

Syr. simplicis, 3jv; 

Aq. menthse, 5jss. 

M. S.: A teaspoonful every hour or two, or several times a day. 

This is to be used in connection with saline irrigations of the colon. 



CHAPTER IX 



THE DIGESTIVE SYSTEM — Continued 

PROCTOLOGICAL MEMORANDA (RECTAL AILMENTS) 

Svnopsis: Preliminary Remarks. — Catarrh of the Rectum (Simple, Syphilitic, Atrophic 
Follicular). — Periproctitis and Abscess. — Impacted Faeces. — Foreign Bodies. — Condy- 
lomata (Syphilitic; non-Syphilitic). — Haemorrhoids (Internal, External). — Rectal 
Polyps. — Rigid Sphincter. — Pruritus Ani. — Prolapse of the Rectum. — Simple Fissure 
and Painful Ulcer. — Ulceration and Stricture of the Rectum. — Neuralgia of the Rec- 
tum. — Coccygodynia. — Remarks on the Upper Rectum and Sigmoid Flexure. 

PRELIMINARY REMARKS 

Examination. — An examination of the rectum is made by the finger 
and by means of a speculum in direct or reflected light. The upper rectum 
and sigmoid flexure may be inspected with the " Kelly tube." Constriction 
of the calibre of the intestine from organic disease or by pressure from with- 
out, and extreme tortuosity of the sigmoid flexure with adhesions, may 
prevent the use of instruments. A long flexible silver probe is useful for 
exploring fistulous tracts. The most comfortable and delicate position 
in which the patient may be examined is on the left side; the left arm 
brought behind the body, the right shoulder turned away from the examiner, 
the right thigh well flexed upon the abdomen. 

In interrogating the patient we inquire as to pain, protrusion of parts, 
discharge, gonorrhoea, bowel action, haemorrhage, syphilis, menstruation, 
and pregnancy. 

Before examining the patient the bowels must be moved, and in some 
instances local or general anaesthesia is necessary to a thorough examination. 
A knowledge of the state of the heart, kidneys, lungs, liver, central nervous 
system, and genital organs is essential to correctly interpret some of the 
conditions found in the rectum. 

In the management of rectal disease, as in the treatment of nasal disease, 
local treatment is of prime importance in conditions requiring operative 
interference, but in the various catarrhal conditions too much local treat- 
ment often prolongs the trouble, and therefore general hygienic manage- 
ment steps to the foreground. The interdependence of rectal and genito- 
urinary disturbances must not be overlooked. 

CATARRH OF THE RECTUM; PROCTITIS 

On careful local examination we can distinguish four forms: 
Simple acute catarrh, hypertrophic catarrh, atrophic catarrh, and follicular 
inflammation. 

304 



PROCTITIS AND IMPACTION OF F.ECES 



;;o:, 



Proctitis is a catarrhal inflammation of the mucosa from many causes. 
There is a sense of heat and weight in the perinaeum, with a constant desire 
to defalcate. The anus is hot and tender, and there is a mucous discharge. 
This form of inflammation may terminate in speedy resolution or develop 
into periproctitis, abscess, fistula, or ulcer. 

General Treatment. — Remove the cause if possible. Order a dose of 
castor oil or a saline cathartic, a cold compress to the parts, or a suppository 
of opium and belladonna, aa, gr. 

In periproctitis with ischiorectal abscess the treatment is the same as 
in proctitis, and as soon as an abscess is evident, open it freely and pack 
the wound to allow it to heal from the bottom. A dressing of balsam of 
Peru or ichthyol ointment, 10 per cent, is advisable. 

Chronic atrophic catarrh is a common ailment. A dry, brittle condition 
at the margin of the anus is characteristic of this affection and gives rise 
to intractable pruritus. In addition, there is constipation with dry stools 
and some mucous discharge. 

Treatment. — Cleansing the intestinal tract with salt solution and inject- 
ing half an ounce of a 5 or 10 per cent solution of argonin is appropriate 
treatment. Where there is distinct ulceration the insufflation of aristol or 
iodoform is excellent. Hydrochloric acid may be required to aid digestion. 

Hypertrophic catarrh is found in plethoric individuals. There is a persist- 
ent moisture at the anus, the stools are soft, liquid, or mucous, and there 
is marked flatulence with poor digestion. 

Treatment. — Phosphate of sodium before breakfast, a general tonic, 
hygienic measures, and hydrochloric acid to aid digestion. Locally, we 
inject into the rectum from one to six ounces of a 25 per cent solution of 
aqueous extract of krameria. 

Follicular inflammation, or catarrh, of the rectum shows a hyperaemic 
mucous membrane with small nodular, elevated swellings. Patients 
afflicted with this form of catarrh do not have a satisfactory stool, but go 
to the closet several times a day and pass small round masses coated with 
this mucus, and complain of flatulence. 

Treatment. — The treatment is local and constitutional, as in the other 
forms. 

IMPACTION OF FAECES 

The term impaction is used when the accumulation of faeces takes place 
in the pouch of the rectum. It may occur at any age and is due to inertia 
of the intestine or spasm of the sphincter, and it should be noted that a 
fluid discharge from the bowels (diarrhoea) is not incompatible with great 
retention of solid faeces. 

Diagnosis and Treatment. — The diagnosis is made by digital examination, 
and the impacted mass is removed by breaking it up with the fingers or by 
means of a spoon handle. After the patient is relieved, general hygienic 
and tonic management, including massage, are indicated. 

A rigid sphincter is often associated with fissure and is the cause of 
many cases of constipation in children and adults. It requires digital 
divulsion under narcosis by means of the thumb and index finger. This 
effort must be continued until the muscle has lost its power. 



306 



THE DIGESTIVE SYSTEM 



Foreign bodies in the rectum are detected by digital examination and 

are removed under narcosis if necessary. 

Condylomata, warts, excrescences, vegetations, and mucous tubercles 

occur at the anus and vulva. There are two varieties: Condylomata lata 
and condylomata acuminata. Condylomata may be of syphilitic origin or 
may be due to irritation and filth. Those of syphilitic origin disappear 
after specific treatment and cauterization with nitrate of silver or chromic 
acid. The others may be snipped off with sharp scissors, and the bleeding 
spots should be cauterized. 



Definition. — A sinus left by an abscess in the neighborhood of the anus. 
A blind fistula has no communication with the intestine. A complete 
fistula communicates with the lumen of the intestine. The external orifice 
may be of the size of a pin or lie in the centre of a mass of granulations. 
The fistula secretes a thin purulent fluid. Now and then the orifice becomes 
obstructed, the discharge collects, a small abscess forms, and the skin becomes 
hot and tender. When this breaks, the symptoms subside. A certain pro- 
portion of anal fistulas are of tuberculous origin. In making a bacteriological 
diagnosis the Smegma bacillus should not be mistaken for the tubercle 
bacillus. 

Treatment. — The parts are made anaesthetic by means of cocaine or, 
according to Gant, by injections of sterile water under the skin. A grooved 
director is passed into the fistula and out through the anus and the tissues 
are divided until the director is free. Peroxide of hydrogen is now sprayed 
on the wound and the latter packed with iodoform gauze. The patient can 
go about on the following day, wearing a diaper or bandage. An incomplete 
fistula is made complete by forcing the grooved director through into the gut. 



Definition. — A varicose condition of the vessels around the anus, fre- 
quently associated with eversion of the rectal mucous membrane. 
External haemorrhoids are of two kinds: 

a. A tag of skin somewhat inflamed. 

b. A thrombotic or blood clot haemorrhoid. 

The symptoms of both varieties are very much the same, heavy, weighty 
feeling and an aching pain. Some piles have an ulcerated surface. 

Treatment. — a. Palliative. A laxative medicine, heat or cold to the 
part, and subsequently the following ointment: 



FISTULA IN ANO 



HEMORRHOIDS (PILES) 



1$ Calomel., 

Ext. opii, 

Ext. belladonna?, 

Vaselini albi, . . . 




3ss.; 



5j. 



gr. x; 



M. S. : Apply frequently. 



An ointment of tannin, opium, and belladonna, or of cocaine, gr. x, 
carbolic acid, gr. xx, and vaseline, Sj, is also effective. 



FISTULA AND HEMORRHOIDS 



307 



b. Operative. The skin haemorrhoid may be cut off at its base with 
a pair of scissors. The thrombotic pile should be slit open with a sharp 
knife and the blood clot released. The wound may be dressed with car- 
bolated vaseline. 



These are troublesome on account of haemorrhage, protrusion, and pain. 
They can readily be distinguished from a polypus, which has a pedicle, and 
from prolapse of the rectum by its velvety appearance and uniformity of 
circumference. Cancer and ulceration of the rectum cannot be mistaken 
for haemorrhoids by a careful examiner. Among the local causes of haemor- 
rhoids may be mentioned as of importance any condition which interferes 
with the return flow of blood from the rectum, tumors, the gravid uterus, 
constipation, and circulatory obstruction of hepatic, renal or cardiac origin. 

Treatment. — a. Palliative. The first indication is to prevent faecal 
accumulation and establish soft stools. With that' object in view, we not 
only resort to certain medicines, but we must put the patient on appro- 
priate diet and under good hygienic surroundings. Absolute cleanliness of 
the anus and irrigation with tannic acid and alum are among the latter. 
Of medicines, rhubarb and its preparations, and pulv. liquirit. comp., are 
useful, but all drastic purgatives are to be avoided. When bleeding is 
copious, injections of fl. ext. of hamamel. virg., a teaspoonful to a wine- 
glassful of water, used once daily, are sufficient. In the event of an 
" attack " of inflammation the patient is put to bed, the bowels are kept 
open, and heat or cold is applied. An ointment of opium and belladonna 
or cocaine is serviceable. After the " attack," daily cold water enemata 
may be continued for a long time. 

b. By Injection. A solution of carbolic acid may be injected into the 
protruding haemorrhoidal tissue once a week: 



This process takes several weeks to effect a cure. The instruments 
required to give the injections are: 

1. A hypodermic syringe of glass and a platinum needle two inches long. 
The needle can be readily sterilized by making it red hot in the flame of an 
alcohol lamp. 2. A rectal speculum with a section of its wall cut out and 
replaced by a sliding piece. This permits of the inspection and treat- 
ment of isolated portions of the bowel. 3. Aluminum or silver cotton car- 
riers with cotton for mopping and cleansing the parts. 

The patient is to have an enema a few hours before treatment. The 
small tumors are injected first, and the trifling pain from the needle can be 
overcome by applying a 5 per cent cocaine solution to the parts on a cotton 
swab. Two or three piles are injected at each sitting. Piles that do not 
protrude can be reached by means of the speculum. Two sittings a week 
can be safely carried out. 



Internal Hemorrhoids 



~Bj, Acid, carbolic, pur., . ) 

Glycerini, > equal 

Aquae, ) 




M. S. : Inject five drops into the centre of the pile. 



21 



308 



THE DIGESTIVE SYSTEM 



c. Operative Treatment. Whitehead's Method. — Resection of the 
entire hemorrhoidal area is an operation of some magnitude, and its 
success depends upon aseptic and primary healing in a region where 
asepsis is difficult to obtain. 

Allingham's operation. — Excision of each hsemorrhoidal tumor, with 
ligation of the vessel at its base, is free from risks and an excellent operation. 

The clamp and cautery operation can be rapidly performed and gives 
very satisfactory results. 

RECTAL POLYPI 

They are found in children and adults. They are pedunculated growths 
attached to the mucous membrane, and may be soft or fibrous, and are 
sometimes multiple. By thoroughly searching the bowel they can be felt 
and seen. They give rise to the following symptoms: Tenesmus, desire 
to go to stool, bleeding, and the passage of mucus. They may protrude 
from the anus on straining. 

Treatment. — They should be removed by means of a torsion forceps or 
by ligature. 

PRURITUS ANI 

Painful itching of the anus is a very distressing minor ailment, often 
very intractable, but eventually curable if the patient will persist in carrying 
out well directed treatment. The itching and irritation are worse at night, 
when the patient is in bed, and they interfere with sleep. Pruritus is 
possibly a pure neurosis, but usually there is some underlying local or 
constitutional cause, such as gout, diabetes, or hepatic disease, hemorrhoids, 
uterine disease, vaginal discharges, constipation, ascarides, or pediculi. 

The treatment must be directed to any underlying constitutional dys- 
crasia and the removal of local irritation. The parts should be thoroughly 
washed several times a day with soda water followed by a 2 per cent car- 
bolic acid solution. If an examination with a magnifying glass reveals 
fissures or breaks in the mucous membrane of the parts, cauterization 
with a 5 per cent nitrate of silver solution is indicated, three times a week. 

The following dusting powders and protecting ointments are useful: 

Stearate of zinc with acetanilide. 



Powdered starch. 
Powdered talcum. 

Py Camphor ice, 5j; 

Acid, carbolic 5ss. ; 

Cocain., . . . gr. x. 

Vaselini, gj; 

Ichthyol., 5j; 

Cocain., gr. x. 

1$ Vaselini, 5j; 

Menthol., 3ss.; 

Bismuth subcarb., 3j- 



In intractable cases of pruritus a division of the nerves leading to the 
parts has been practised with apparent success. 



PROLAPSE, SIMPLE FISSURE AND ULCER OF THE RECTUM 309 



PROLAPSE OF THE RECTUM 

Prolapse or protrusion of the rectum is common in flabby, anaemic, 
and rhachitic children, but may occur at any age. 

Causes. — The causes are a relaxed state of the sphincter muscle, straining 
due to any local cause in the genitourinary and rectal regions, such as 
stricture, stone, a foreign body, a polypus, phimosis, worms, constipation, 
and piles. 

The protruding bowel may be recognized as such by its central aperture. 
In protruding intussusception a sulcus can be made out between the pro- 
truding bowel and the sphincter. In rare instances the protruding bowel 
may become strangulated and slough away. 

Treatment. — Reduction of the protrusion, strapping of the nates, regu- 
lation of the bowels, and rectal injections of cold alum water, 5ij to 1 qt., 
twice a day. General tonic and hygienic management will suffice Tor the 
majority of cases in flabby, anaemic children. 

Should such simple methods fail to cure, linear cauterizations with 
the galvanocautery or actual cautery in the long axis of the bowel are 
necessary and will cause the mucous membrane to adhere to the muscular 
coat by inflammation. In every case a careful examination will be necessary 
in order to exclude or detect and remove any source of local irritation. 

Prolapsus Ani in Children — Paraffin Injections. — For the relief of rectal 
prolapse in children Karewski (C entralblatt }ilr Chirurgie, July 12, 1902) 
has employed subcutaneous injections of paraffin having a melting point 
of 56° to 58° C. The patients, purged for two days, on the day previous 
to operation received large doses of bismuth to lock up the bowels. The 
field of operation was disinfected and the prolapse was reduced. A finger 
was then introduced into the rectum to act as a guide. Through one 
needle puncture the paraffin was injected in the form of a ring above the 
anus between the skin and mucous membrane. By suitable diet and the 
administration of bismuth an evacuation of the bowels was prevented for 
the following twenty-four hours. Eight children between two and eight 
years of age were treated by this method. One case was unsuccessful 
because of a faulty technique, but all the remainder were cured so far as 
could be judged from examinations made in from two to six months after 
the operation. In two cases the paraffin had to be injected a second time, 
and in a case of an idiotic, feeble child a third injection was made. In the 
remaining cases a single introduction of paraffin sufficed. Although in 
some of the cases the bowels moved during or shortly after the opera- 
tion, an infection never occurred, because the injection wound was kept 
protected. 

SIMPLE FISSURE AND ULCER OF THE RECTUM 

These very painful affections are found oftener in women than in men. 
Their location may be anterior or lateral, but it is usually dorsal, near the 
anus or high up in the rectum. They may be single or multiple. They 
are caused by straining and the passage of very hard, dry stools, and other 
causes. The patient complains of great pain on defalcation, and occasion- 
ally blood and matter are found in the stool. The agonizing pain induces 



310 



THE DIGESTIVE SYSTEM 



the sufferer to postpone relieving the bowels as long as possible, and generally 
produces a high degree of nervous irritability. The site of the fissure or 
ulcer is often marked by a club-shaped papilla, more or less inflamed, 
protruding from the anus. On introducing the finger the ulcer is readily 
detected and is quite painful to the touch. 

Treatment. — A laxative should be taken at night, and the following 
ointment should be frequently applied: 



An occasional light touch with nitrate of silver is useful. 

Should the ulcer or fissure fail to heal by such management, the patient 
must be anaesthetized and the sphincter should be stretched thoroughly. 
A speculum is now introduced and the edges of the ulcer are cut away with 
a pair of sharp scissors and a knife is drawn over the ulcer, cutting through 
its base and if necessary into and through the external sphincter at right 
angles to its circular fibres. At the same time the aforementioned pro- 
truding club-shaped skin flap is also cut away. As a dressing, the above 
ointment will answer. This procedure will effect a cure. A fissure will 
heal after a thorough stretching of the sphincter. 

Ulceration located high up in the intestine requires irrigation through 
the colon tube every other day with \ per cent nitrate of silver solution 
followed by normal saline solution. On alternate days an emulsion of 
bismuth, 5j> iodoform, gr. x, olive oil, Siv, should be injected and retained. 
As a final resort, an artificial anus should be established and irrigation 
practised from above. 



Congenital strictures have been mentioned in the chapter on Diseases 
of the New-Born. 

Acquired strictures may be due to pressure and constriction from without 
(pelvic inflammation), cancer, cicatrices from simple or dysenteric ulcera- 
tion or from injury, cicatrices from tuberculous ulcers, cicatrices from syphi- 
litic ulceration, cicatrices from soft chancre and gonorrhoea and unnatural 
practices. The syphilitic variety is often combined with condylomata. 
Fissures may form below the stricture, and haemorrhoids are a frequent 
concomitant. 

Symptoms, Diagnosis, and Prognosis. — Local pain, radiating pain, 
difficulty in having a motion, constipation alternating with diarrhoea, 
with the motions small and streaked with mucous discharge. In addition, 
there are general dyspeptic symptoms and belching of wind, and the patient 
becomes anaemic and worn out by constant suffering or from profuse haemor- 
rhage, and unless relieved dies of exhaustion or obstruction and peritonitis. 
There are often sympathetic vesical disturbance and loss of sexual power. 

The diagnosis is made by local examination with the finger and 
speculum, and when the trouble is high up, by means of Kelly tubes or an 



Calomel, 

Extr. opii, 
Extr. belladonna? 
Vaselini alb., . . . . 




gr. x; 



gr. xxx; 



5j. 



ULCERATION AND STRICTURE OF THE RECTUM 



NEURALGIA OF THE RECTUM AND COCCYGODYNIA 311 



exploratory laparotomy. The great point to be decided is the distinction 
between cancer and non-malignant disease. Cancer of the rectum gen- 
erally runs its course in two or three years. A cancerous mass is hard to 
the touch, nodular, irregular, and without a pedicle, and involves ad- 
jacent parts. It may also present as a deep ulceration or a bleeding 
fungous mass, and frequently we find enlarged glands in the groin or in 
the hollow of the sacrum. In doubtful cases the microscope will aid in 
diagnosis. 

Even greater difficulties confront us when attempting to distinguish 
between the various forms of non-malignant strictures. Dysenteric ulcera- 
tion and contraction is known by its history. Tuberculous disease may be 
suspected from a coexisting lung trouble or from the patient's general 
condition. A reliable history of syphilis may justify the diagnosis of 
syphilitic stricture, and finally we must not forget that unnatural sexual 
intercourse, resulting in injury or infection, may be the cause of ulceration 
and contraction. 

Treatment. — Fibrous strictures can be overcome by dilatation, with 
and without linear incision (proctotomy). If syphilis or tuberculosis 
is the underlying cause, hygienic treatment and specific medication (with 
mercury, potassium iodide, etc.) must be employed at the same time. 
Electrolysis accomplishes little or nothing. Colotomy and extirpation of 
the rectum must be employed in otherwise intractable cases. Colotomy is 
indicated in old and incurable cases of non-malignant ulceration, stricture, 
and fistulse which are threatening life by exhaustion or obstruction. It may 
be indicated in obstruction exterior to the bowel, in cases of intestino- 
vesical fistula, and in " inoperable " cancer of the rectum, or when excision 
is for any reason contraindicated. The benefits of colotomy are manifest. 
The choice lies between the inguinal and the lumbar operation. Ability 
of the patient to care for the opening and secure cleanliness is in favor of 
the inguinal site. Opium or morphine must not be denied the sufferer 
from malignant strictures. 

NEURALGIA OF THE RECTUM 

A severe and sickening pain in the rectum, not aggravated by the action 
of the bowels, and for which there is no apparent local cause. It is not 
infrequent in older children and adults of a neurotic type, is more apt to 
come on in times of worry and excitement, and may come on during sleep 
and keep the sufferer awake for hours. 

Treatment. — Hygienic management, cold sponge baths, avoidance of 
constipation, and in severe cases a stretching of the sphincter muscle are 
indicated. If the patient is anaemic, iron or arsenic is indicated. If he 
is very neurotic, the bromides are to be given for a short time. Vibratory 
massage gives prompt relief in many cases. 

COCCYGODYNIA 

Definition. — Neuralgic pain in the sacrococcygeal joint. Not infrequent 
in neurotic women. 



312 



THE DIGESTIVE SYSTEM 



Treatment. — The treatment is the same as for neuralgia in the rectum. 
A careful examination, to detect if possible a local source of irritation, 
should be made. In rare instances excision of the coccyx is necessary. 

THE UPPER RECTUM AND SIGMOID FLEXURE 

This region is accessible to some extent by means of the Kelly tubes. 
New growths, ulcers, and catarrhal conditions are found to exist here as 
in the lower rectum. 

The non-operative treatment consists in flushing the parts with saline 
or boric acid solutions and the local application of astringents and healing 
remedies. Hygienic measures and open bowels are the foundation of all 
treatment. Too much local treatment, particularly in catarrhal conditions, 
is meddlesome and harmful. 

The so called morning diarrhoea and mucous diarrhoea are generally due 
to some pathological condition of the rectum, sigmoid, or descending colon. 



CHAPTER X 



THE DIGESTIVE SYSTEM — Continued 

DISEASES OF THE LIVER, GALL BLADDER, BILE DUCTS, 
PANCREAS, PERITONAEUM, OMENTUM, AND ABDOMINAL 
LYMPH NODES 

Synopsis: Diseases of the Liver. — Preliminary Remarks. — Corset Liver. — Floating Liver' 
— Displaced Liver. — Jaundice. — Acute Congestion of t he-Liver, Active and Passive. — ■ 
Acute Yellow Atrophy of the Liver. — Chronic Hepatitis (Cirrhosis), Atrophic and 
Hypertrophic Forms. — Abscess of the Liver and Pylephlebitis. — New Growths of the 
Liver. — Echinococcus of the Liver (Hydatid Cysts). — Chronic Degenerative Processes 
of the Liver. — Syphilis of the Liver. — Atrophy of the Liver. — Fatty Degeneration of 
the Liver. — Fatty Infiltration of the Liver. — Amyloid Liver. — Inflammation of the 
Serous Coat of the Liver. — Aneurysm of the Hepatic Artery. 

The Gall Bladder and Bile Ducts. — Catarrh of the Bile Ducts. — Acute Inflammation 
of the Gall Bladder. — Gallstones. — Courvoisier's Law. — Dropsy and Empyema of 
the Gall Bladder. — Gallstones, Acute and Chronic Obstruction. — Indications for 
Operative Treatment. — Cancer of the Biliary Apparatus. 

Diseases of the Pancreas. — -General Remarks. — Acute Hemorrhagic Pancreatitis. — Acute 
Suppurative Pancreatitis. — Tumors of the Pancreas. — Pancreatic Calculus. 

Diseases of the Peritonasum, Omentum, and Mesenteric Glands. — Acute Peritonitis. — 
Subphrenic Abscess. — Chronic Peritonitis. — Cancer of Peritoneum and Omentum and 
Cysts. — Acute and Chronic Inflammation and Degeneration of Abdominal Lymph 
Nodes. 

DISEASES OF THE LIVER 

GENERAL REMARKS 

In order to fully understand the clinical pathology of the liver, the fol- 
lowing points should be borne in mind. The blood pressure in the portal 
capillary system is extremely low. Therefore minute disturbances may 
impede the flow of blood and produce passive congestion in the liver, and 
chemical and bacterial poisons from the intestines and in the blood and 
metastases of malignant growths readily affect the liver. Under normal 
conditions the liver dulness in the mamillary line extends from the lower 
border of the sixth rib to, or slightly beyond, the sternal border. 

Fluids in the right thorax, a massive indurated lung, exudates and tumors 
between the liver and diaphragm, and tumors of neighboring organs may 
simulate enlargement of the liver. Tympanites and ascites make the liver 
dulness appear small. Deductions based upon a small liver dulness should 
be carefully weighed. A large, tender, or very hard liver is not in a normal 
condition. A deformed frhachitic) thorax may give to the liver an ab- 
normal position. 

313 



314 



THE DIGESTIVE SYSTEM 



Corset liver and lobed liver are sometimes caused by tight lacing and 
by wearing tight belts. 

A floating liver, or dislocated liver, is a rare condition which when found 
is probably an associated feature of pendulous belly and may be due to a 
congenital defect in the suspensory ligaments of the organ. A floating 
liver may give rise to various reflex symptoms and attacks of colic, which 
may be overcome to a large extent by the wearing of an abdominal support, 
as discussed in the chapter on Enteroptosis. 

JAUNDICE AS A SYMPTOM 

Jaundice may manifest itself in disease of the liver and in various other 
conditions in which the free flow of bile into the small intestine is interfered 
with. When the flow of bile is obstructed, and its production by the liver 
parenchyma continues, we have an overfilling of the gall bladder and a 
resorption of bile by the lymphatics into the general circulation, as shown 
by the icteric pigmentation of the tissues from light yellow to brown or 
green. The urine, the sweat, and inflammatory exudates show this colora- 
tion. The tears, saliva, and gastric juice do not as a rule appear yellow. 
The cholates of the bile also get into the circulation and act as systemic 
poisons. Jaundice is not dependent upon complete obstruction of the 
large bile duct, and any localized obstruction in the liver may be associated 
with jaundice. In gallstone colic with incomplete obstruction jaundice is 
often absent. 

The symptomatic jaundice in infectious septic conditions and in certain 
intoxications (phosphorus) is probably due to fatty degeneration of the 
liver cells, in which condition absorption may take place without obstruc- 
tion. Although we know that bilirubin may form from haemoglobin, 
owing to changes which take place in blood extravasation, it is pretty 
well established that a jaundice without the aid of the liver cells is not 
likely. 

Whenever bile fails to get into the intestine, nutrition is markedly 
interfered with, and when bile enters the circulation the cholates act as 
nerve poisons, blood pressure is diminished, the heart becomes slow and 
irregular in action, and coma may set in (cholsemia). A thick, tenacious 
bile is more readily absorbed than a thin bile. Cholsemic symptoms depend 
upon the concentration of the poison in the blood, so that we may observe 
intense jaundice without much constitutional disturbance. On the other 
hand, coma, convulsions, delirium, fever, etc., are observed in icterus 
gravis as well as in hepatic disease with little or no jaundice. 

Symptoms Associated with Jaundice. — In jaundice of long standing, 
we notice a tendency to haemorrhage from the mucous membranes (acquired 
hsemorrhagic diathesis), and we find the urine to contain albumin and hyaline 
casts in addition to bile. The skin, mucosa, and conjunctiva turn yellow, 
brown, or green. The skin becomes blotchy and itches. The stools are 
clay colored, pasty, and foetid. The heart's action is slow, notwithstanding 
a moderate rise of temperature, and the pulse may be intermittent. The 
patient is irritable, depressed, delirious, or comatose (typhoid state) and 
may have convulsive seizures. 



CATARRHAL JAUNDICE IN OLDER CHILDREN AND ADULTS 315 



Clinical Forms of Jaundice. — Jaundice of the new-born, mild and septic 
(see Paediatrics), mild catarrhal jaundice, at all ages, icterus gravis of hepatic 
origin (acute, chronic, infectious, and obstructive), infectious jaundice, and 
toxic jaundice. 

Jaundice with Reference to Its Origin: 

Gastroduodenal catarrh, catarrh of the bile ducts, 
gallstones or worms in the bile duct, pressure on the duct 
by tumors of any neighboring organ or fsecal accumulation 
or aneurysm, cicatricial stenosis of the bile duct, pressure 
of the gravid uterus. 

Acute and chronic hepatitis, acute yellow atrophy of 
the Liver. 

Microbial toxines (infectious disease), epidemic jaun- 
J dice, jaundice following vaccination, influenza, typhoid 
] fever, and other infections, also tonsillar infection, chenil- 
le cal poisons, snake venom. 



Obstructive 
Jaundice. 



Hepatic 
Jaundice. 

Toxemic 
Jaundice. 



Prognosis. — The prognosis of jaundice cases depends upon the under- 
lying cause. The mild, catarrhal form in children and adults terminates 
favorably in from one to six weeks. In the new-born, the mild form lasts 
from a few days to three weeks. Severe infectious jaundice in the new-born 
is usually fatal. 

The infectious, or toxic, jaundice in older children may last three to 
four months, particularly if occurring in subjects with fatty liver, and may 
end in recovery or death. In severe obstructive forms recovery depends 
upon our ability to remove the cause. In jaundice of long standing an 
exploratory laparotomy is indicated with the hope of finding and removing 
an obstruction (gallstones, stricture). 



CATARRHAL JAUNDICE IN OLDER CHILDREN AND ADULTS 

Treatment. — In mild, non-febrile cases the patients may be treated out 
of bed. Febrile and severe cases should rest in bed. 

Diet. — Milk, meat, eggs, cereals and other soft diet, stewed fruit, 
pineapple or orange juice, beef jelly, wine, tea, tropon in peppermint tea, 
water, Vichy, or Carlsbad water. Fat is to be avoided. Usually there is 
a loathing of food and the appetite must be tempted by offering palatable 
articles. 

Medication. — Five to ten grains of calomel should be given at once, 
followed by a saline cathartic. Carlsbad salts or sodium phosphate may be 
given frequently to keep the bowels free. To aid digestion, five drops of 
dilute hydrochloric acid should be given in water, after eating. The so 
called cholagogues are probably useless. Large quantities of water by the 
mouth and per rectum are imperatively demanded. In protracted cases, in 
which syphilis or malaria is suspected as an underlying cause, quinine or 
Warburg's tincture may be given by the mouth or potassium iodide per 
rectum, In severe indigestion rectal alimentation may be employed, and 



316 



THE DIGESTIVE SYSTEM 



the patient should remain in a covered hot bath, 105° F., for an hour daily, 
with the object of eliminating the systemic poison through the skin. Mild 
massage is beneficial. 

Itching may be controlled by powdering with starch or sponging with 
a warm soda solution. Furuncles and cold abscesses should be opened as 
soon as fluctuation is evident. 

HYPEREMIA OR CONGESTION OF THE LIVER 

The liver, like any other organ, is subject to active and passive conges- 
tion. An active physiological hyperemia takes place during digestion. 
Thus, a heavy eater with little or no exercise may suffer from a liver which 
is actively or passively congested all the time. Active congestion is ob- 
served in malarial disease and dysentery and in diabetes. Passive conges- 
tion is the rule in pulmonary and cardiac disease and obstruction to the 
inferior cava. The nutmeg liver is often an evidence of such conditions at 
autopsies. 

Symptoms. — Hepatic congestion reveals itself by a dull, heavy feeling 
in the region of the liver and by a painful stitch. The patient prefers to 
lie on the right side. Dyspeptic symptoms are marked and slight jaundice 
may be observed, and the liver is enlarged and tender to the touch. A 
diagnosis of congestion of the liver means nothing unless we elicit the 
underlying cause at the same time, for it may be due to overfeeding and 
laziness, or it may be the beginning of hepatic cirrhosis, or it may be 
secondary to cardiac or pulmonary disease. 

Treatment. — The treatment will vary with the cause. The best way 
to influence a congested liver is by dieting (plain mixed diet, 2,000 calories), 
by exercising, and by purging with calomel, podophyllin, blue mass, or 
Carlsbad salts. 

In passive congestion from cardiac and pulmonary disease, and par- 
ticularly if dropsy is present, an infusion of digitalis should follow in the 
wake of a brisk purge, or venesection should be done. Carlsbad salts in 
hot water, in the morning, may be taken for a long time in hepatic congestive 
conditions. 

ACUTE YELLOW ATROPHY OF THE LIVER; MALIGNANT JAUNDICE 

This is a rare but fatal disease which may be defined as an acute infec- 
tion of the liver in which there is a rapid disintegration of the liver cells 
accompanied by great reduction in the size of the organ, with deep jaundice 
and grave nervous symptoms. The condition is similar to that produced by 
phosphorus poisoning. 

Symptoms. — The principal symptoms, extending over two to four weeks, 
are jaundice, vomiting, delirium, haemorrhages, and rapid atrophy of the 
liver. Leucine, tyrosine, bile, and albumin are found in the urine. 

In the way of treatment nothing can be done beyond cleansing the 
alimentary tract and stimulating the patient. 



CIRRHOSIS OF THE LIVER 



317 



CIRRHOSIS OF THE LIVER 

Definition. — A chronic hepatitis characterized by enlargement and 
subsequent atrophy, the liver being usually hard and small at the terminal 
stage of the disease. There is another class of cases called the hypertrophic, 
or biliary, form. Both are the result of an abnormal development of con- 
nective tissue, with contraction as a prominent feature in one, but not in 
the other. In the hypertrophic form the sufferer probably dies before the 
stage of contraction is reached. 

etiology. — Chronic hepatitis is due to microbial infection of the liver 
through the circulation and from the intestinal tract. Alcoholism and 
gastrointestinal fermentation are predisposing factors, also syphilis and 
malaria. The disease is most frequent in middle aged men and is also 
found in children; in the latter malaria, congenital syphilis, scarlet fever, 
and gastrointestinal fermentation are the predisposing factors. 

Symptoms and Diagnosis. — All forms of cirrhosis have practically the 
same symptoms, which are obstructive and toxic. The obstructive symp- 
toms are chronic gastric catarrh, occasionally haemorrhage from the ali- 
mentary canal, epigastric distention, enlargement of the spleen and of the 
epigastric veins, ascites and fluid in various cavities and oedema of the 
feet. Jaundice is often present. The spleen is generally enlarged, the urine 
is diminished and concentrated and may contain albumin, especially in 
the later stages, and the stools have a light color. The liver is large and 
tender in the hypertrophic stage and haemorrhoids are present. There is 
nothing characteristic as to the range of temperature. Dyspnoea is often an 
early symptom. In biliary cirrhosis (hypertrophic form), jaundice is almost 
as intense as in biliary obstruction, but the stools remain colored. The 
toxic symptoms are delirium, stupor, coma, and convulsions, as in any 
other form of toxaemia, and they occur in the terminal stage. 

The diagnosis of cirrhosis may be quite difficult to make, and only large 
clinical experience will enable us in some cases to distinguish between chronic 
passive congestion, cancer, amyloid liver, and tuberculous peritonitis with 
ascites. A condition of perihepatitis is sometimes observed at the autopsy 
in cases of hepatitis, the capsule of the liver being thickened. Pain is a 
prominent symptom in this class of cases. 

Prognosis. — The prognosis of advanced cases is unfavorable. 

Treatment. — As the disease in its early stages, when it might be in- 
fluenced by treatment, is frequently not recognized, the treatment of its 
pronounced manifestations is naturally symptomatic. However, it is no 
more than right that a patient suffering from chronic hepatitis should 
receive the benefit of such specific treatment as we possess, and in each 
and every case a course of antiluetic and antimalarial treatment is to be 
tried. Failing in our efforts in this direction, our symptomatic treatment 
will be conducted on the following lines: Enemata or laxatives, to secure 
daily bowel movement; ten drops of hydrochloric acid and ten drops of 
tinct. gentian, com., in water, after each meal, to aid digestion; daily moder- 
ate exercise and mild general massage and massage of the abdomen; a 
liberal diet (2,000 calories), avoiding cabbage, beans, pork, pastry, and fried 
fish; alcohol in moderation not to be forbidden for those who are accus- 



318 



THE DIGESTIVE SYSTEM 



tomed to it; carbonated alkaline waters (Vichy), ginger ale, and pepper- 
mint tea are drinks to be recommended. 

Operative Treatment of Ascites and Cirrhosis of the Liver. — 
The writer was the first to employ permanent drainage for the relief and 
cure of ascites from cirrhosis and from other causes. The modus operandi 
of this procedure is described and illustrated in the article on Ascites. 

Talma's operation (the suture of the omentum to the peritonaeum) is 
not indicated in ascites due to causes other than cirrhosis of the liver. 
Permanent drainage and Talma's operation are indicated in cirrhosis of 
the liver in cases in which internal medication (particularly with iodide of 
potassium) and paracentesis fail to afford relief, and in those cases in which 
there is no reasonable contraindication. 

ABSCESS OF THE LIVER AND SUPPURATIVE PYLEPHLEBITIS 

Hepatic abscess is always due to infection, but traumatism may be a 
direct incitive factor. The various pathological factors which give rise to 
abscess formation in the liver may be grouped as follows. Infection by 
means of foreign bodies (needle, fishbone, gallstones). Infection by means 
of parasites (echinococcus, round worms, amoeba, actinomycosis, etc.). 
Infection by means of pysemic embolism, from suppurative pylephlebitis, 
typhoid ulcer, ulcer in dysentery, tropical abscess, appendicular ulcer, 
pelvic suppuration, gangrene of the intestine, puerperal sepsis, gall bladder 
suppuration, etc. 

The infecting agent may reach the liver by way of the portal vein or 
hepatic artery. The abscess may be solitary or multiple. The so called 
" tropical liver abscess " occurs most frequently in the hot countries. 
Sporadic cases of tropical liver abscess are encountered as exotic manifesta- 
tions in the temperate zones. Hepatic abscess is at times the result of 
trauma; usually, however, it is the result of invasion of the hepatic tissue 
by various forms of parasites, protozoa, and pyogenic organisms. 

Symptoms. — The cardinal symptoms are irregular fever, chills, and septic 
phenomena, sweats, enlargement of the liver, hepatic and right shoulder 
pain, moderate jaundice, a sallow complexion, and gallstone disturbances. 
In doubtful cases aspiration of the liver is indicated. 

Differential Points. — In malarial fever the Plasmodium is found in 
the blood, and the administration of quinine brings improvement and 
cure. In typhoid fever we observe roseola and frequently a positive Widal 
reaction. Hepatic abscess may complicate typhoid fever. 

A right sided pyothorax may result from hepatic abscess breaking through 
the diaphragm into the pleural cavity. The aspirated pus in such cases 
is brownish in color and liver cells may be found with the aid of the micro- 
scope. Rapid cardiac failure with congestion of the liver and excruciating 
pain has been mistaken for hepatic abscess. 

The prognosis is grave. 

Treatment.— Surgical: When adhesions have formed between the 
liver and the abdominal wall and the abscess points, simple incision and 
drainage are indicated. When this is not the case, operative interference 
involves the opening of the abdominal cavity in order to have access to the 



NEW GROWTHS OF THE LIVER 



319 



liver. The single large abscesses offer the best chance for an operation. 
Pysemic abscesses and suppurative pylephlebitis are generally fatal. 
The non-surgical management is that of septicaemia. 

NEW GROWTHS OF THE LIVER 

The malignant new growths are primary and secondary cancer, including 
cancer of the bile passages; primary and secondary sarcoma. Clinically, 
carcinoma and sarcoma of the liver cannot be distinguished one from 
another. They are classified under one heading and will be spoken of as 




; -. — ~ i— - ~~ c- -. — ! — : ^ . 

Fig. 114. — Cancer of the Liver (Dr. Halsey's case). 



"cancer." Cancer of the liver is usually secondary. It is a disease of 
late adult life and rarely occurs in children. It is less common in the 
tropics and in malarial districts than elsewhere. 

Symptoms. — Progressive enlargement of the liver, gastric disturbances, 
progressive loss of flesh and strength, pain or discomfort in the right hypo- 
chondrium, moderate jaundice in half the cases, ascites occasionally, 
palpable cancerous nodules in the late stages, a smooth liver surface in 
diffuse cancer, oedema of the feet usually, cachexia and anaemia marked, 
no characteristic fever curve, a duration of less than two years, and previous 
or concomitant carcinoma of other organs. 

Differential Points. — In hypertrophic cirrhosis the jaundice is deep, 
cachexia is less marked, and liver surface is smooth. In syphilitic amyloid 



320 



THE DIGESTIVE SYSTEM 



liver with projecting gummata there is a syphilitic history and there is less 
cachexia. A large, nodulated hydatid liver is recognized as such by puncture. 

Treatment. — Palliative treatment by hypnotics and sedatives is all 
that we can offer our patient at the present time. Whenever there is an 
element of doubt as to syphilis, an inunction course should be tried. Loeffler, 
of Germany, has recently recommended inoculation of malarial poison 
against carcinosis, and Beaton, of England, reports that carcinosis in women 
can be influenced by removing their ovaries. The influence of animal 
extracts and of x rays on carcinosis is still unknown. 

HYDATID CYSTS OF THE LIVER (ECHINOCOCCUS) 

The cyst is formed by the larva? of taenia, is unilocular or multilocular, 
and gives no marked symptoms in its incipient stage. A large cyst may 
present as a fluctuating swelling. If situated to the left of the suspensory 
ligament, pressure on the heart may result. The cysts may perforate any 
neighboring hollow organ. When suppuration in the cyst takes place, 
pyaemic symptoms supervene. The hydatid fremitus is a diagnostic sign 
in echinococcus cysts. In simple cysts the general health may be good. 
When hydatid cysts rupture or are punctured, urticaria often develops 
from absorption of irritating fluid. 

Differential Points. — In order to distinguish between hepatic abscess, 
carcinoma, and hydatid cyst, a puncture is necessary. Multilocular cysts 
and carcinoma cannot be distinguished without puncture. Dilatation of 
the gall bladder and hydronephrosis have been mistaken for echinococcus 
cysts. An examination of the puncture fluid will reveal the condition 
present. Hydatid cysts have been mistaken for right sided pleurisy. 
The puncture fluid of echinococcus shows albumin and free fluid containing 
hooklets. Sterile cysts contain no hooklets, and cysts which have been 
irritated may show albumin in the fluid. 

Treatment. — Medication and injections into the cyst are useless. When 
simple aspiration fails to cure, incision is indicated. 

CHRONIC DEGENERATIVE PROCESSES IN THE LIVER 

The conditions to be briefly described under this heading have more 
of a pathological than clinical interest, inasmuch as they represent patho- 
logical incidents in the course of various systemic diseases. 

Atrophy of the Liver may result from all forms of cachexia or marasmus. 
The liver is small. 

Fatty Degeneration is observed in poisoning by phosphorus and in acute 
infections. The liver is small. 

Fatty Infiltration is often associated with general obesity and severe 
anaemia. It is quite common in children in gastroenteric and other acute 
infections. The liver is enlarged. 

Amyloid Liver is observed in the cachexia of chronic suppuration, 
chronic malarial disease, chronic gout, syphilis, leucaemia, and pseudo- 
leucaemia. The liver is enlarged. 

In all these conditions a consideration of the underlying cause leads 
to the diagnosis, gives the prognosis, and indicates the treatment. 



GALLSTONES 



321 



Syphilis of the Liver. — In congenital syphilis of the liver we observe dif- 
fuse infiltration, gummata, and chronic induration (syphilis hereditaria tar- 
da). In acquired syphilis, the diffuse infiltration and gummata are present. 

The treatment is antisyphilitic and sustaining. 

DISEASES OF THE GALL BLADDER AND BILE DUCTS 

ACUTE CATARRH OF THE BILE DUCTS (NOT CAUSED BY GALLSTONES) 

This inflammation is due to an extension of gastroduodenitis from 
indigestion, infection, or passive congestion. The cardinal symptoms are 
jaundice and indigestion. If the jaundice persists longer than three months, 
an exploratory laparotomy may be indicated in order to locate and remove 
if possible a serious obstruction. Otherwise, the prognosis is favorable 
and the treatment is that of catarrhal jaundice. 

Acute Inflammation of the Gall Bladder is an infection of this organ, 
with or without the presence of gallstones. The symptoms are those of 
hepatic colic, paroxysmal pain, oftentimes jaundice, local tenderness, fever, 
nausea, vomiting, abdominal distention and rigidity, and general prostration. 

The differential points in diagnosis will be discussed under Gallstones. 
In doubtful cases a probatory puncture into a palpable swelling or distended 
gall bladder is indicated, or an exploratory laparotomy is demanded. 

Treatment. — Mild manifestations of gall bladder inflammation may 
subside under the application of a hot water bag to the parts, a brisk cathar- 
tic, and subsequently morphine subcutaneously to quiet pain. When the 
symptoms become urgent and suppuration and sepsis are suspected or are 
evident, the treatment becomes surgical. An operation is required in 
nearly all cases of empyema or dropsy of the gall bladder and in persistent 
recurring colic from inflammatory adhesions. Aspiration through the abdom- 
inal walls will not affect a cure and is hazardous. The choice of oper- 
ation after opening the seat of disease lies between cholecystotomy, cho- 
lecystectomy, and cholecystenterostomy, and must be left to the judgment 
of one who is experienced in this class of surgery. 

GALLSTONES 

Concrements from bile are deposited generally in the gall bladder and 
occasionally in other parts of the bile tract in and outside of the liver. 
They occur in all sizes and numbers. They are composed of cholesterin, 
lime salts, bilirubin, etc. Normal bile is sterile and is kept sterile by a 
centrifugal flow of bile. Microbial invasion may take place through the 
circulation during typhoid fever and grippe or by way of the intestines. 
This invasion of microbes is favored by a stagnation of bile, viz. : an atro- 
phic condition of the gall bladder from old age, gravidity, and tight lacing. 

Microbial invasion produces catarrhal conditions of the lining of the 
gall ducts. Epithelia with undissolved cholesterin are detached and form 
centres of crystallization or deposit, and the nucleus or starting point of 
gallstone formation is thus afforded. Concrements in the gall ducts do 
not invariably irritate, but they frequently give rise to pain, inflammation, 
adhesions, abscess, and perforation. 



322 



THE DIGESTIVE SYSTEM 



The microbic theory of gallstones is now an established fact. It is 
probable that the microorganisms favor the precipitation of certain elements 
of the bile, but the microbes cause a catarrh, which may not be recognized 
clinically. The degeneration of the epithelial cells produces the cholesterin 
and lime. 

Lithiasis is a result of the infection of the whole biliary tract or of the 
gall bladder alone. 

Calculi may be divided into two classes — those produced by the colon 
bacillus and those by the typhoid bacillus. The colon bacillus is the most 
frequent cause. The presence of aseptic foreign bodies in the gall bladder 
does not produce inflammation and does not seem to affect its function, if 
the cystic duct remains patent. There is no precipitation of cholesterin 
when the bile remains clear and free from microbes. 

Bile, stagnant in an aseptic gall bladder, has no tendency to precipitate. 
It is probable that the microorganisms find their way into the gall bladder 
through the duodenal opening of the common bile duct. The possibility 
of entrance through the blood vessels must be allowed, but has not been 
proved. 

If the ductus cysticus becomes occluded, we observe dropsy of the gall 
bladder or eventually empyema with ulceration and perforation into the 
liver, intestine, stomach, or peritonaeum. Malignant growths often find a 
foothold on perforating ulcers. Cholelithiasis and carcinosis are companions. 

Gallstone colic is associated with great pain, vomiting, fever, and occasion- 
ally jaundice. Spasmodic contraction of the gall ducts produces pain just 
as we observe it in the ureter and intestine. Children are not subject to 
gallstones and women are more subject than men. 

Symptoms, Diagnosis, and Differential Points. — As long as a calculus 
remains free in the gall bladder no urgent symptoms are produced. When 
impaction occurs in the cystic or common bile duct, urgent symptoms are 
manifest. Colic is the main symptom, accompanied by nausea, vomiting, 
sweating, a rapid pulse, depression, and frequently, but by no means in- 
variably, jaundice, for an impacted gallstone need not entirely obstruct 
the flow of bile. 

As a rule there is fever of an indefinite intermittent type during an attack 
of gallstone colic. The pain of biliary colic is acute and cutting and is 
localized in the region of the gall bladder, whence it spreads over the ab- 
domen, thorax, and back and frequently into the right shoulder. The 
liver and gall bladder are tender, particularly if the hand is pushed beneath 
the free border of the thorax. 

The duration of an attack varies; it may be over in an hour or two, and 
with remissions and exacerbations may last a week or two until the stone is 
expelled. Impaction in the cystic duct may develop without jaundice and 
may distend the gall bladder into a palpable tumor which, unlike a wander- 
ing kidney, moves with respiration. Occasionally gallstone crepitus may be 
perceived. As a result of cystic duct impaction, we observe dropsy of the 
gall bladder or inflammation and empyema of the gall bladder. In case of 
perforation by the stone, a localized abscess or general peritonitis may ensue. 

Courvoisier's Law. — Of distinct value in practical diagnosis is the ob- 
servation of Courvoisier, made in 1890, in regard to the enlargement of the 



GALLSTONES 



323 



gall bladder from obstruction of the common duct. The law is this: When 
the common bile duct is obstructed by a stone, the gall bladder does not 
enlarge, whereas when the obstruction occurs from other causes, enlarge- 
ment is generally present. In explanation of this anomaly it is suggested 
that if there is a stone in the common duct, there are probably several 
others in the gall bladder, the presence of which excites inflammatory action, 
this in turn being followed by a contraction of the tissue walls of the viscus. 

Impaction in the common duct gives rise to jaundice and symptoms 
of catarrhal and suppurative cholangeitis. There is an intermittent presence 
of bile in the stools, occasionally fever, and some enlargement of the liver. 
The gall bladder may be distended or atrophic. 

Differential Points. — A colic as described, plus jaundice and a history 
of previous attacks, makes the diagnosis of gallstone almost positive. 
After an attack the stools should be passed through a rotating flour sieve 
and search made for the stone. 

In locali :ed paroxysmal pain without jaundice we must discriminate 
from the following conditions: In inflammation and adhesions of the gall 
bladder without stone the absence of stone can be made out only at the time 
of operation (Morris' spider cases). In renal colic the pain radiates from the 
lumbar region into the lower abdomen, groin, thigh, and testicle. The 
lumbar region is often tender on pressure and the urine may show blood, 
haemoglobin, and calculi. In gastralgia the pain is in the middle epigastrium 
and radiates more to the left; fever and jaundice are absent, and no gall- 
stones are found in the stools. In appendicitis the pain is localized over the 
appendix, the appendix is tender on palpation, jaundice and tenderness of 
the liver and gall bladder are not observed, and a gallstone is not found in 
the stools after the attack. In enteralgia or intestinal colic the pain is in 
mid-abdomen and is relieved by pressure and the passage of flatus. 
Jaundice is absent and stones are not found in the stools. 

Complications and Sequelas. — Gallstones may be expelled at irregular 
intervals, with symptoms of colic not urgent enough to demand operative 
interference, and a cessation of the symptoms may result. Stones of all 
sizes may pass or ulcerate into the bowels and be discharged with the stools. 
Very large stones may cause intestinal obstruction. Stones may ulcerate 
and perforate into any neighboring organ or locality and produce abscess, 
fistula, or peritonitis. 

Treatment. — The prompt way of relieving the intense pain of gallstone 
colic is to give a hypodermic injection of morphine (gr. | to J), to be repeated 
if necessary. The patient may also place a hot water bag over the seat of 
pain and drink hot peppermint tea. In lieu of hypodermic medication the 
following prescription for internal use is offered: 



Py Morphin. sulph., gr. j; 



Chloroformi, 1 




Pulv. acacise, J 



Aquae, ad., giij. 

M.: ft. emuls. et adde 



Syr. sacch., 5jv. 

S. : A teaspoonful every half hour untd the patient is relieved. 



22 



324 



THE DIGESTIVE SYSTEM 



After the attack the bowels must be kept open by Carlsbad salts or 
enemata. 

The indications for operative treatment vary with each individual case. 
The age of the sufferer is to be considered. Patients with a senile heart 
are not promising subjects for operative interference. An exploratory 
laparotomy in doubtful cases is better than theoretical speculation. If 
after opening the abdomen the conditions are found to be favorable for 
radical operative measures, they should be employed. An operation per- 
formed while the stones still remain in the gall bladder or cystic duct gives 
the best results. 

MORTALITY AFTER OPERATIONS FOR GALLSTONES* 
1. 237 Conservative operations (cystostomies, cystendyses, cysticotomies), 



with 5 deaths 2.1 per cent 

2. 161 Cystectomies, with 5 deaths 3.1 " 

3. 137 Choledochotomies, with hepaticus drainage, with 9 deaths 6.5 " 

4. 114 Simultaneous operations on the stomach, intestines, pancreas, liver, 

kidney, etc., with 24 deaths 21 " 

5. 71 Simultaneous operations in "inoperable" carcinoma of the gall blad- 

der, choledochus, liver, diffused suppurative cholangeitis, diffused 
suppurative peritonitis, sepsis, with 69 deaths..... 97 



Total: 720 laparotomies, with 112 deaths 15.5 per cent 

Deducting (4) 114 operations, and 
(5) 71 operations. 



* 535 Uncomplicated laparotomies for gallstones, with 19 deaths, 3 . 5 per cent. 
— Professor Hans Kehr, of Halberstadt, Germany, 1902. 

CANCER OF THE BILIARY APPARATUS 

Cholelithiasis and carcinosis are companions. Cancer of the gall bladder, 
if primary, is almost invariably associated with gallstones. Frequently it 
is secondary to cancer of the liver and neighboring organs. 

Symptoms. — Pain, tenderness, chronic jaundice, fever, cachexia, hsemat- 
emesis, etc. Sometimes a tumor can be felt. A positive diagnosis is made 
by exploratory laparotomy. The disease is fatal. 

DISEASES OF THE PANCREAS 

GENERAL REMARKS 

The pancreas is situated in the curve of the duodenum, across the first 
and second lumbar vertebra?, and is extraperitoneal. It occupies the region 
from six to twelve centimetres above the umbilicus. The gland is of the 
compound racemose type and secretes a very active digestive fluid. This 
fluid consists of four well known ferments, acting upon separate classes 
of food: Trypsin, acting upon the proteids, changing them into peptones; 
amylopsin, acting upon the starches, converting them into maltose and then 
into glucose; rennet, coagulating the milk when in the presence of an 
acid; and steapsin, emulsifying the fats and changing them into soap. 
The amount of pancreatic secretion in a case of Cushing's was found to be as 
high as 660 grammes daily, and all was not then obtained. This is a much 



ACUTE SUPPURATIVE PANCREATITIS 



325 



larger amount than was formerly believed to be secreted by the gland 
The curve of the amount secreted was greatest during the day and decreased 
as the night advanced and the upper intestines were emptied. This action 
corresponds with the belief that food stimulates the flow of the pancreatic 
secretion. The nerve supply is probably through the pancreatic, but the 
mode of action is not definitely known. The sympathetic system may also 
be found to have some influence, because the amount of secretion varying 
with the amount of food to be acted upon in the intestines indicates a close 
nervous relation between these organs. 

Hcemorrhage into the pancreas is one mode of sudden death. The patients 
are previously well and are taken with sudden severe epigastric tenderness 
and pain, increasing in severity and colicky in character. Nausea and 
vomiting usually follow, and the patient becomes anxious and restless. 
The pulse is weak and rapid and later becomes imperceptible. The tem- 
perature is that of shock, normal or subnormal. Tympanites is sometimes 
marked. The bowels are usually constipated. The diagnosis is certainly 
most difficult, and if it is made, surgical relief would be indicated. 

ACUTE HEMORRHAGIC PANCREATITIS 

Acute inflammation accompanied with small haemorrhages into the 
interlobular tissues usually occurs in males with an alcoholic history. The 
onset is sudden, with violent colicky pain in the upper abdomen, nausea, 
vomiting, and collapse. Constipation is the rule. The abdomen becomes 
swollen and tense. The temperature is at first low, then high. Delirium 
usually accompanies the attack. The condition must be distinguished from 
acute perforative peritonitis and intestinal obstruction. 

Treatment. — The treatment would be symptomatic. Prescribe rest in 
bed, unload the bowels, apply cold over the abdomen, and order a fluid diet. 

ACUTE SUPPURATIVE PANCREATITIS 

The inflammation may occur as a single focus or as diffuse suppurative 
foci. The symptoms are not clear, but are usually of some duration. The 
attack may come on suddenly with severe pain, vomiting, fever, and 
delirium. A deep seated mass may be felt in the median line above the 
umbilicus. This may be accompanied by an attack of jaundice and fatty 
diarrhoea, with or without sugar being present in the urine. When glyco- 
suria has been present, destruction of the islands of Langerhans has been 
found at the necropsy. 

Treatment. — The treatment would be surgical. 

Gangrenous inflammation of the pancreas may follow any of the follow- 
ing conditions: Acute hcemorrhage, acute inflammation, simple or suppura- 
tive, injury to the organ, and perforative ulcer of the stomach. 

The whole or a portion of the organ may be involved, and the disease 
may terminate in death or recovery in two or three weeks. 

Diagnosis. — The diagnosis of the condition would depend upon the 
history and symptoms, which are very much like those of suppurative 
pancreatitis. 

Treatment. — The treatment of such a condition would be surgical. 



326 



THE DIGESTIVE SYSTEM 



Chronic inflammation of the pancreas is usually associated with a chronic 
catarrhal process of the stomach, duodenum, or bile ducts, and is an ex- 
tension through the ducts. A few cases may follow syphilis, alcoholism, 
and general arteriosclerosis. The inflammation may be haematogenic, 
due to toxines in the blood, and hence follow typhoid fever, influenza, or 
some other toxaemia. If infection is the cause, prolonged drainage of the 
gall bladder has been recommended. 

Atrophy of the organ is usually associated with diabetes, or chronic 
interstitial inflammation of the head of the gland, or a blocking off of the 
ducts. 

TUMORS OF THE PANCREAS 

Tumors of the pancreas are usually carcinomatous, rarely sarcoma, 
adenoma, lymphoma, tuberculous, or syphilitic. The head of the organ 
is usually the seat of the disease, though the body or tail may be involved. 
The growth usually occurs in people of middle life. 

Diagnosis. — The diagnosis of the condition is not often possible, as 
there are no regular symptoms and the growth may be present without 
symptoms. The most common association of symptoms is the following: 
Rapid cachexia and pain, which may be continuous or paroxysmal and 
situated in the epigastrium. Nausea and vomiting may coexist. Jaundice, 
from occlusion of the common duct with distention of the gall bladder, 
may be severe and increasing. The presence of a tumor is very variable 
and may or may not be made out. Pulsation, with or without a bruit, 
may be discovered. Thrombosis of the portal vein and its sequelae may 
complicate the condition. Symptoms from loss of function are not common, 
hence fatty diarrhoea is not frequent. The stools are clay colored and 
greasy from the absence of bile. Diabetes is rare. Dilation of the stomach 
and stenosis of the pylorus from pressure of the growth may exist. If 
the diagnosis is made early, the only hope lies in complete extirpation of 
the growth, including all involved glands and tissue; otherwise the outlook 
is hopeless. 

CYSTS OF THE PANCREAS 

Cysts are due to inflammation, or retention from occlusion. 

The history of one variety involves blows or oft repeated pressure over 
the pancreas as the existing cause. The symptoms are pain and vomiting 
and later the pressure of a tumor. Following inflammation there are 
severe symptoms coming on suddenly with pain and obstruction of the 
ducts, causing the later development of the tumor. Without preceding 
trauma or inflammation, there may be cystic formation from retention by 
plugging of the main ducts, or from proliferation of glandular tissue and 
occlusion of a duct, or many small occlusion cysts from chronic interstitial 
changes in the alveoli. 

It seems proper to mention here the pseudopancreatic cysts due to 
haemorrhage into the lesser sac of the peritonaeum. Such a condition 
may follow trauma or inflammation, and resembles in position and symp- 
toms true cysts of the pancreas. The anatomical situation of these cysts 



TUMORS AND CYSTS OF THE PANCREAS 



327 



is in one of three places: In the lesser sac between the stomach and colon; 
rarely if ever above the stomach; and between the peritoneal layers of the 
transverse mesocolon. Thus the physical signs of the tumor will appear in 
one of these three positions, in the epigastrium, with only slight lateral 
displacement from the median line. 

Irrespective of the anatomical position, the symptoms in general of 
all of these cysts are similar, though every one is not necessarily present in 
each instance — attacks of colicky pain, nausea, and vomiting, with progres- 
sive enlargement of the abdomen. Fatty diarrhoea is rare, as is salivation. 
Glycosuria, however, is frequent. Jaundice may occur from pressure 
obstruction of a duct. Dyspnoea may be present, due to the size of the 
cyst. In some cases there may be loss of flesh. Sudden temporary dis- 
appearance of the cyst may occur, due to the discharge of its contents into 
the intestinal canal. 

Physical signs of these cysts depend, as stated above, upon the anatomical 
position. Hence the tumor usually appears as a hemispherical bulging 
in the median line of the upper abdomen, rarely as a lateral tumor. It is 
immobile and unaffected by deep inspiration. As a rule, the stomach is 
above and the colon crosses below. The aspirated fluid is reddish or dark 
brown in color, containing blood, blood coloring matter, and cell detritus, 
with fat granules. The consistence is mucoid and the reaction alkaline. 
The specific gravity varies from 1,010 to 1,020. It may contain one or 
all of the pancreatic ferments, but the digestion of fibrin or albumin is the 
only reaction regarded as a positive sign. The absence of all ferments is 
not regarded as negative proof. 

The following conditions must be distinguished from pancreatic cysts: 



Malignant Tumors 

Pain continuous. 
Loss of flesh and strength. 
Progressive local and general in- 
fection causes a multilocular cyst. 
Hardness. 
Surface nodular. 
Duration of months. 

Aneurysm of the Abdominal Aorta 
Expansile pulsation. 

Bruit. 

Size diminished by steady pressure. 
Peritonitis 

Fever. 
Pain. 

Tenderness, 



Pancreatic Cysts 

Not usually present until large. 
Rarely. 

Usually unilocular. 

Cystic feel. 

Smoothness. 

Weeks. 

Pancreatic Cysts 

Pulsation ceases in the knee-chest 
position. 

Not affected by pressure. 

Pancreatic Cyst 
Symptoms less intense. 



328 



THE DIGESTIVE SYSTEM 



Ascites 
Causes for ascites. 

Aspirated fluid gives character. 

Cystic Ovary 
Examination and history. 

Hydronephrosis or Pyonephrosis 

History points to the kidney or 
ureter. 

Examination of the urine. 
Dulness below the kidney posteri- 
orly. 

Echinococcus Cyst 

Peculiar pseudocrepitus. 
Multilocular. 

Presence of hooklets in the aspirated 
fluid. 

Retroperitoneal Glandular 
Enlargement 

Preceding history and other symp- 
toms. 

Cyst of the Suprarenal Gland 

Not possible 



Pancreatic Cysts 

History and onset of symptoms 
differ. 



Pancreatic Cyst 
Digestive disturbances. 

Pancreatic Cyst 



Tympany in the lumbar region be- 
low the kidney. 



Pancreatic Cyst 



Not present. 
Unilocular. 



Pancreatic Cysts 



Pancreatic Cyst 
to distinguish. 



PANCREATIC CALCULUS 

This condition is rare and its symptoms are seldom defined sufficiently 
to make a diagnosis. The concretions are usually multiple and resemble 
fragments of white coral. In substance they are carbonate of calcium. 

The symptoms, if present, are due for the most part to the effects of 
the stone on the gland; hence we observe a chronic interstitial inflammation 
of glandular substance with dilatation of the duct. This condition may 
go on to the formation of cysts. There may be acute suppurative inflamma- 
tion of the gland. The irritation of the deposit may be followed by car- 
cinoma. Under the foregoing conditions, the symptoms leading to sup- 
puration from stone would be severe colic, fatty diarrhcea, and glycosuria 
without other explanation. 



ACUTE PERITONITIS 



329 



SURGERY OF THE PANCREAS 

The advance of pancreatic surgery has been greatly hindered by the 
difficulties of diagnosis and by the great danger attendant upon operation 
on this gland, particularly from leakage of the pancreatic secretion, which 
seriously irritates the peritonaeum. 

The results of operations in chronic pancreatitis are encouraging. 

DISEASES OF THE PERITONAEUM, OMENTUM, AND 
MESENTERIC GLANDS 

The peritonceum is the inner lining of the abdomen and pelvis, and 
is reduplicated at various points so as to partially or completely envelop 
the various intrapelvic and intraabdominal organs. 

Clinical Varieties of Peritoneal Inflammation. — The clinical varieties are 
ascites (hydroperitonaeum), acute peritonitis (diffuse and localized), sub- 
phrenic abscess, chronic peritonitis, diffuse and localized (simple, tubercu- 
lous, syphilitic, gonorrhceal, and malignant). 

Peritonitis is an inflammation of the peritonaeum, and on opening the 
abdomen in such cases we find clear or cloudy or hemorrhagic effusion, 
creamy or foul pus, and plastic lymph deposits, and in case perforation of 
the intestine has taken place we may find faecal matter in the abdominal 
cavity. 

Clinically, we recognize acute, subacute, and chronic peritonitis with 
periods of quiescence and periods of exacerbation of inflammatory symp- 
toms. Peritonitis may result from injury with infection (including imperfect 
surgical technique), from an extension of an inflammatory process of a 
neighboring organ with or without perforation, and from metastasis through 
the blood and lymph channels in all infectious and septic processes. We 
have evidence of prenatal peritonitis in the shape of intraabdominal ad- 
hesions and bands. In the new-born septic peritonitis may develop from 
the navel. In childhood and adult life severe enteritis, appendicitis, 
typhoid ulcer, tuberculosis, trauma, and infection are the exciting factors 
in peritonitis. 

When the causative factor is unknown, we speak of idiopathic peritonitis. 
In the present state of our knowledge this term is too indefinite and un- 
satisfactory and had better be dropped. 

ACUTE PERITONITIS 

A primary, or idiopathic, peritonitis is supposed to occur as a terminal 
event in chronic nephritis, arteriosclerosis, and gout. Acute primary 
infection is theoretically as likely as the infection of any other serous 
membrane through the blood, but practically almost all of our cases of 
peritonitis are secondary, viz. : By extension of a neighboring inflammation, 
by perforation of gastrointestinal ulcers (simple, tuberculous, cancerous, 
stercoraceous, or typhoid, or due to intestinal stone), by rupture of any 
neighboring pus sac, as in appendicitis, pyosalpinx, and by pyaemic infec- 
tion (puerperal infection). 



330 



THE DIGESTIVE SYSTEM 



Symptoms. — When the patient is already ill and a slow spreading gen- 
eral peritonitis develops as a complication, the onset may be sudden or 
slow and insidious. The pain becomes general, the abdomen tender, dis- 
tended, and tympanitic, and the patient's knees are drawn up to minimize 
abdominal tension. The respiration is costal and rapid (30 to 40) , vomiting 
may be persistent (green vomit), and the pulse is rapid and small (110 to 
150). The temperature may be normal or subnormal or high. The urine 
contains much indican, and there is a tendency to collapse. The face is 
anxious, the skin is cold, and the mind may be quite clear. On examination 
the abdomen is found motionless or rigid, and on auscultation we may hear 
peristaltic restlessness, or in case of intestinal paresis we notice an absence 
of intestinal gurgling. The hepatic dulness soon disappears and an effusion 
may become manifest. 

Differential Points. — In severe enterocolitis simulating peritonitis there 
is profuse diarrhoea with only moderate meteorism and abdominal rigidity. 
In intestinal obstruction there is no decided rise of temperature, no passage 
of flatus or faeces, and faecal vomiting generally occurs. The high tempera- 
ture and rigid abdomen are marked only in the later stages. In rupture 
of an ectopic gestation sac there is a characteristic previous history — no 
fever, breast signs, menstrual irregularities, with a small pulse and collapse 
after the rupture. 

Acute localized peritonitis occurs principally in three varieties: Pelvic 
peritonitis, peritonitis around the appendix, and subphrenic peritonitis 
or abscess. "Pelvic peritonitis is discussed under Gynaecological Memoranda. 
Appendicular abscess is discussed under Appendicitis. 

Treatment of Acute Peritonitis. — The management of acute general 
peritonitis depends upon circumstances and the underlying cause. Hot 
water or ice bags may be applied locally over the abdomen and full doses 
of opium may be given by the mouth, or morphine (gr. J-) and atropine 
(g r - tto) subcutaneously. The diet should be diluted milk, slimy gruel, 
white of egg in water, tea, peppermint tea, champagne, water ice, ice cream, 
tropon, 5j to a cup of tea, and ice to suck. 

If vomiting persists, rectal alimentation must be relied on, and one 
drop of tincture of iodine should be given in a teaspoonful of sweetened 
peppermint tea every hour. The lower bowel may be flushed with a pint 
of warm saline solution once or twice a day. When the infection is wide- 
spread, it may become necessary to open the abdomen and flush with 
hot salt water. There are no strict rules to guide us as regards indications 
for operative interference in diffuse peritonitis; each case must be judged 
upon its merits. A localized peritonitis and abscess formation require 
prompt incision and drainage. As a heart stimulant, camphor in oil, sub- 
cutaneously, or benzoate of sodium and caffeine, subcutaneously, is in- 
dicated. 

The prognosis in diffuse peritonitis is grave. The pulse is the best 
index to the gravity of the infection. A rapid pulse and incessant vomiting 
and high septic temperatures, all combined, give a fatal outlook. 



SUBPHRENIC AND CHRONIC PERITONITIS 



331 



SUBPHRENIC PERITONITIS (ABSCESS) 

A subphrenic abscess is an accumulation of pus between the liver and 
the diaphragm or between the stomach, the spleen, and the diaphragm. 

Causation. — Perforation of a gastric or duodenal ulcer. Upward ex- 
tension of any intraperitoneal inflammation or abscess, or any form of 
suppuration taking its origin in the liver, gall bladder, stomach, spleen, 
circumrenal tissue, pancreas, appendix, intestine, hydatid cysts, or trauma. 
Downward extension of an empyema through the diaphragm. In some 
instances we have to deal with a subphrenic abscess containing air — pyo- 
pneumothorax subphrenicus. 

Subphrenic abscess occurs in adults and in children. The writer has 
seen two instances in children, one taking its origin from the perforated 
appendix in a girl of five and the other from a perforation of the ascending 
colon, left side abscess, in a girl of ten. Both patients recovered after an 
operation. 

Symptoms of Subphrenic Abscess. — The symptoms may come on ab- 
ruptly or insidiously. In addition to the general symptoms of sepsis, 
such as fever, chilis, and rapid pulse, there are localized pain and tender- 
ness, vomiting, and embarrassed respiration. There may be bulging of 
the tissues on the side in which the abscess is located. Sometimes a suc- 
cussion sound may be elicited. If the abscess contains air, there will be 
an area of tympanitic percussion sound between the liver and lung. As- 
piration under such conditions may bring forth foul smelling air instead of 
pus. Often a swelling with local oedema is noticeable. A friction sound 
may be heard over the complementary pleural space (9th to 11th rib). 
If there is much pus, the liver dulness will extend unduly upward. Similar 
phenomena will be elicited on the left side, minus the liver dulness. Eventu- 
ally the subphrenic abscess may rupture into the thoracic cavity and com- 
municate with a bronchus. In suspected cases aspiration should be done 
in the 7th or 8th interspace in the mid-axillary line or immediately above 
the supposed liver dulness. 

Prognosis. — The prognosis is grave. Early recognition and prompt 
operation and drainage may save life. Incision should be made over the 
centre of the dull area or wherever the probatory puncture reveals pus or 
foul air. As a rule a resection of the 8th, 9th, or 10th rib in the mid-axillary 
line will be indicated, or an incision in the interspace between the 7th and 
8th ribs in the anterior axillary line. Should this lead into the free thoracic 
cavity, a second puncture downward may be made in order to locate the pus. 



CHRONIC PERITONITIS 

The peritonaeum may participate in the chronic inflammatory condition 
of organs in contact with it (localized chronic peritonitis) and may suffer 
by reason of chronic infection of the serous membrane itself, resulting in 
diffuse adhesive peritonitis. Apart from cancer and tuberculosis, a pro- 
liferative chronic peritonitis is described by Osier, which is found in chronic 
alcoholism and possibly in syphilis, 



332 



THE DIGESTIVE SYSTEM 



The symptoms are persistent abdominal pain of a colicky character 
and occasionally intestinal obstruction due to fibrous bands. On opening 
the abdomen in such cases, the coils of the intestines are found matted 
together, the peritonaeum is thickened, the omentum forms thickened masses, 
and a serous effusion may be present. 

The most interesting form of chronic peritonitis is the tuberculous variety, 
which is seen more often in children and is described in the pediatric 
section of this book. 

CANCER OF THE PERITONAEUM AND OMENTUM 

This is usually secondary to malignant disease of the abdominal or 
pelvic organs, and is observed in persons past middle life. There is per- 
sistent ascites or bloody effusion, with loss of flesh and cachexia, and large 
nodules are felt on palpation. 

Differential Points. — Tuberculous peritonitis occurs mainly in children. 
In hydatid disease hooklets may be found in the puncture fluid. In doubtful 
cases an exploratory laparotomy is to be done. Cancer of the peritonaeum 
is incurable. Morphine and opium should be given to allay the pain. 

THE OMENTUM AND MESENTERY 

These structures frequently participate in whatever befalls the peri- 
tonaeum, and thus we observe syphilis, tuberculosis, and cancer of the 
omentum, the diagnostic features of which have been discussed. 

Cysts of the Omentum or Mesentery containing a brownish fluid have 
been observed. Hydatid cysts are rare. 

The treatment is by aspiration and laparotomy. 

Thrombosis of mesenteric blood vessels gives symptoms of peritonitis. 

MESENTERIC AND RETROPERITONEAL GLANDS 

The lymph nodes in this region may become acutely inflamed or may 
undergo tuberculous, syphilitic, or malignant degeneration. 

Tabes Mesenterica, a tuberculous glandular enlargement, presents a 
distinct clinical picture and may be associated with tuberculosis of the 
peritonaeum and intestine. Children suffering from this disease are puny, 
anaemic, and wasted, with a large tympanitic abdomen, diarrhoea, and 
fever. In cases difficult to diagnosticate the tuberculin test may be em- 
ployed. A blood examination is of value, also a temperature record ex- 
tending over two to three weeks. Indentable scybala should not be 
mistaken for enlarged glands. 

The prognosis is uncertain. 

The treatment is that of tuberculosis in general. 



CHAPTER XI 



THE CIRCULATORY SYSTEM 

Synopsis: Remarks on the Clinical Pathology of the Circulation. — Congenital Heart De- 
fects. — Clinical Aspects of Hypertrophy and Dilatation. — Acute Circulatory Failure 
(Heart Strain, Shock, Collapse). — Endocarditis. — Pericarditis. — Pericardial Adhe- 
sions. (Continued in Next Section.) 

REMARKS ON THE CLINICAL PATHOLOGY OF THE 
CIRCULATION 

An efficient circulation is of fundamental importance to the organism 
and depends upon the condition of the motor (heart) and the elasticity 
of the vessels. Vasomotor influence is exerted in such a manner that nor- 
mally one organ may be hypersemic and another anaemic without disturbing 
the general circulation. There is also an aspirating mechanism furnished 
by the right heart and the lungs, supplemented by the contractions of 
muscles and fasciae. Owing to a well recognized reserve power, the accom- 
modation of the heart muscle to the various demands made upon it is very 
complete in health. Great and continued expenditure of force is followed 
by hypertrophy of tissue, just as in the skeletal muscles. Thus, any im- 
pediment to the circulation, be it located in lungs, kidneys, liver, or blood 
vessels, will put a strain upon the heart and produce hypertrophy, that is, 
more heart muscle, in order to overcome the resistance. The so called 
reserve power in the heart is present in hypertrophic hearts as well as in 
normal hearts, although not in the same degree. When arterial pressure is 
permanently increased, there is danger of rupture of capillaries (on exer- 
tion), particularly in arteriosclerosis. 

Unusual heart fatigue and heart strain may be followed by distention 
or dilatation of the heart. Recovery from distention may take place sooner 
or later, but occasionally a heart is thus permanently damaged. Heart 
strain is particularly dangerous in chronic degeneration of the heart muscle 
or following acute infectious fevers, such as typhoid or diphtheria, and in 
pertussis, etc. 

The position and size of the heart are made out by means of inspection, 
percussion, palpation, auscultation, and direct vision through the agency of 
x rays. Such knowledge must be acquired at the bedside and cannot be 
learned from books. In transposition of the viscera the heart is sometimes 
located on the right side (dextrocardia). In a rhachitic thorax the position 
and size of the heart cannot be judged if the left nipple is taken as a guide. 
In such cases it is best to take our measurements from the midsternal line. 

The lungs cover the heart and large blood vessels, excepting a part of 
the right ventricle. The area of the uncovered heart is called the area 

333 



334 



THE CIRCULATORY SYSTEM 



of superficial dulness; that of the whole heart, the area of deep dulness. 
The heart is movable. Thus, the apex beat and heart dulness will move 
to the left if the patient's body during examination tilts to the left side; 
and it does not always mean enlargement if the apex beat is to the left of 
the nipple. In many people no apex beat, or heart shock, is felt. The 
term cardioptosis is occasionally used in connection with a heart which 
by reason of a laxity of attachment is very movable. 

In order to determine the borders of the heart, the lungs and pleura 
must be clear. The diameter of the heart is greater during forced expira- 
tion than during inspiration. The size and position of the heart and the 
decrease in size of a dilated heart improving under treatment may be 
observed by means of the Rontgen rays. 

The pulse should be felt at both wrists to see if it is synchronous. 
Auscultation of the heart and examination of the pulse at the same time 
will distinguish between systolic and diastolic phenomena. The pulse 
may be slow, rapid, intermittent, arrhythmic, small, large, or trip hammer. 
An imperfect heart systole may manifest itself as an intermittent pulse. 

Murmurs. — Regarding murmurs, it may be remarked that not all sys- 
tolic murmurs mean a valvular lesion, and thus we speak of accidental 
murmurs and of functional murmurs. We hear musical, rough, soft, 
blowing, scraping, and vibratory murmurs. In children accidental murmurs 
are comparatively rare. 

Accidental heart murmurs are as a rule systolic and offer no direct 
indications for treatment, as they are not connected with organic changes 
in the valves, papillary muscles, or chordae tendineae. 

Diminution of heart pressure and transitory disturbances of the motor 
function of the heart may cause temporary insufficiency of a valve and 
produce a heart murmur (junctional murmur). 

Pericardial friction sounds may be mistaken for heart murmurs. A 
murmur may make its appearance during illness and subsequently disappear 
completely. Heart murmurs which disappear on holding the breath are 
of cardiopulmonary origin, and not endocardial. 

When the heart beats rapidly, as in fever, heart murmurs may disappear 
or accidental murmurs may arise; therefore, heart sedatives may be given 
for diagnostic purposes to reduce the forcible and rapid action of the heart 
and bring out murmurs if present. A murmur that accompanies the normal 
heart sound is of less gravity than one that replaces it. 

The pulmonic second sound is accentuated when there is pressure behind 
the valve, but such phenomena are also observed in the normal hearts of 
neurotic individuals. 

Reduplication of the sound indicates that valve action is not simul- 
taneous or is out of time, or the heart strain is present (nephritis). A 
reduplication of the first sound is frequently heard when there is high 
arterial tension, as in aortic stenosis or kidney disease. 

The most satisfactory way of auscultation is the direct one. The 
stethoscope is an aid to the dull ear, however. 

As the size of the liver and its tenderness are important guides to the 
degree of venous stasis, they should always be ascertained in connection 
with an examination of the heart, as also the examination of urine. When 



INFLUENCE OF A WEAK HEART ON THE CIRCULATION 



335 



albumin and casts are found in heart insufficiency it becomes important to 
know which is 'primary, the heart or kidney trouble. This may be ascertained 
by a careful weighing of all the evidence, and thus the treatment will be 
better directed. 

In heart weakness, or insufficiency, a complicating hydrothorax is often 
present and overlooked. The removal of fluid from the thorax in cases of 
overwhelming heart strain is often followed by subjective relief and lasting 
improvement. 

In children the heart beat is often rapid and occasionally intermittent, 
even in sleep, and the rapid pulse has not the same significance as in adults. 
A slow and irregular pulse, particularly following infectious disease, is of 
graver import in children and justifies a guarded prognosis. 

In speaking of murmurs the author prefers to use the terms systolic 
and diastolic, not being convinced of any gain in clinical clearness by using 
the term presystolic. 

Summary. — The influence of a weak heart on the general circulation 
may be summed up as follows: When both sides of the heart are equally 
or unequally reduced in tone and power, we observe venous stasis with at 
first functional disturbance in the lungs, liver, kidneys, stomach, and 
brain, with their train of symptoms: Dyspepsia, dyspnoea, local pain, 
vertigo, palpitation, etc., with a terminal dilatation and collapse of the 
heart. Whereas a moderate valvular defect is of importance as regards 
accommodation, a dilatation has a serious pathological importance. Venous 
stasis gives a well recognized clinical picture. Cyanosis and turgid veins, 
with and without pulsation of the jugular and other veins, cardiac dyspnoea, 
and hypersemia of the liver and lungs, with a tendency to catarrh and haemor- 
rhage and fluid accumulations in dependent parts and cavities, are the 
components of venous stasis. Cardiac dyspnoea is probably due to swelling 
and rigidity of lung substance from congestion. 

Heart insufficiency, or heart weakness, may be due to muscular insuffi- 
ciency or valvular insufficiency or to both combined. 

It may be primary or secondary to other diseased conditions which 
obstruct the circulation. This distinction has clinical importance, and if 
the underlying cause of circulatory weakness, or heart strain, can be re- 
moved, the heart may regain its integrity. 

In dealing with the patient the terms "weak heart " and "faulty cir- 
cidation " are preferable to the terms heart disease or valvular heart disease, 
from the humane standpoint. The element of fear of sudden death which we 
find in the laity when heart disease is spoken of plays an important part 
in the management of such cases, and the physician may be well aware 
of the exact anatomical nature of the disturbance without unnecessarily 
alarming and harming his patient. 

CONGENITAL HEART DEFECTS 

Children are born with divers heart lesions, such as patency of the 
foramen ovale, patency of the ductus arteriosus, defect in the ventricular sep- 
tum, and lesions at the pulmonary orifice. Prematurity seems to be an 
serological factor. 



336 



THE CIRCULATORY SYSTEM 



Symptoms. — Cyanosis, dyspnoea, cough, convulsions, oedema, and great 
restlessness. In some cases murmurs or intermittent murmurs and an in- 
crease of the dull area of the heart are found on examination. In other cases 
the physical examination is almost negative. Cyanosis is not always present. 

Treatment. — We are unable to cure an anatomical defect of the heart. 
When blue babies, by reason of constant suffering, cry day and night, it 
is necessary to administer a sedative, such as chloral hydrate and potassium 
bromide, to put the child to sleep, and use as occasion demands. Some 
of these patients die during infancy, others succumb to some intercurrent 
disease during childhood, and some grow to maturity. 

CLINICAL ASPECT OF HYPERTROPHY AND DILATATION 

ENLARGEMENT OF THE HEART 

Enlargement of the heart may be due to simple hypertrophy or to 
dilatation or to hypertrophy and dilatation combined. 

Simple hypertrophy of the heart is the direct result of heart strain on 
a heart muscle not markedly degenerated, and it depends upon three factors: 
The duration of the strain, the degree of the strain, and the condition of 
the heart muscle. 

Enlargement may affect the entire organ or one side or only one chamber. 
The changes are most frequent in the left ventricle, because it does the 
principal work in pumping the blood through the body. 

We speak of a primary, or idiopathic, hypertrophy, when it occurs in 
neurotic individuals who have a continued rapid action of the heart fol- 
lowing the abuse of tobacco, beer, or prolonged heavy work (athletes) 
and in gravidity. Any strain upon a skeletal muscle makes it hypertrophic; 
it is just so with the heart muscle. 

We distinguish eccentric and general hypertrophy. Idiopathic hyper- 
trophy is a specimen of general enlargement. 

Hypertrophy is frequently secondary to arteriosclerosis, nephritis, hepa- 
titis, emphysema, pericardial adhesions, and valvular defects; in fact, any 
chronic obstruction to the circulation is followed primarily by hypertrophy, 
which influences its function and ends in dilatation of the heart muscle. 

In ordinary hypertrophy the heart weighs from 500 to 600 grammes. 
Weights up to 1,500 grammes have been reported, but they are rare. 

Symptoms and Physical Signs. — Hypertrophy is a conservative process 
and often gives no symptoms, but frequently there is a sense of fulness, with 
flushing, headache, palpitation, and forcible shock without palpitation. In 
arterial degeneration with hypertrophy of the heart the development of 
miliary aneurysm in the brain and cerebral haemorrhage is common. There 
may be bulging of the pericardium, the area of impulse is increased, and 
percussion shows increased dulness going to the left of the nipple. This may 
be absent, however, if hypertrophy increases the heart in the anteroposterior 
diameter. The pulse is full, strong, and of high tension in cardiac hyper- 
trophy. Enlargement of the heart must be distinguished from mediastinal 
growths, neurotic palpitation, and hydropericardium. Chronic pneumonia 
and pleurisy on the left side, by reason of retraction, may " uncover " the 



HYPERTROPHY AND DILATATION OF THE HEART 



337 



heart and give rise to an extensive area of dulness, which may be mistaken 
for hypertrophy. The latter is difficult to make out in a deformed chest. 

A strong, heavy impulse and apex beat denotes hypertrophy. In peri- 
cardial effusion the heart shock is not visible and is not felt. The sounds 
are distant and muffled. 

Cardiac hypertrophy is clinically divided into three stages: The period 
of development, the period of compensation, and the period of decompensa- 
tion (acute and chronic by dilatation). 

Prognosis is a matter of retained compensation. Hypertrophy may 
be transient from transient causes, such as neurotic palpitation, tobacco, 
and overexertion, and will require sedative treatment, as with bromide of 
sodium and laxatives. 

Hypertrophy and arteriosclerosis will require careful dietetic and hygi- 
enic management in order to prevent, if possible, apoplexy. Otherwise, 




Fig. 115. — Dulness in Hypertrophy of the Left Ventricle. 

Apex beat heaving and carried down and to the left, perhaps outside of the apex outline. 

Apex pointed. 

hypertrophy should be looked upon as a conservative process of nature, 
and our therapeutic indications are directed to the underlying cause and 
to the prevention of dilatation of the hypertrophic heart muscle. 

DILATATION OF THE HEART 

High blood pressure and impaired resistance produce dilatation of the 
heart. Two varieties are recognized: Dilatation with thickening and dila- 
tation with thinning of the heart walls. 

Sudden cardiac failure during exertion is due to dilatation of the heart 
or rupture of a valve. Hearts which have lost their tone from muscular 
degeneration (infectious fevers or valvular defects), if subjected to severe 
strain, are apt to dilate. Mental emotion is supposed to be one of the causes 
of idiopathic dilatation. In pericardial adhesions the heart is apt to dilate. 
Dilatation is the opposite of hypertrophy and causes heart weakness. 



338 



THE CIRCULATORY SYSTEM 



Physical Signs. — Diffused impulse, weak muffled sounds. Dilatation 

may be accompanied by a murmur, and the heart sounds may be absent. 
The pulse is small, weak, quick, and intermittent. On auscultation we 
hear embryocardia, or gallop rhythm. Murmurs formerly present may 
disappear and murmurs may set in and disappear as the heart becomes 
stronger. This is due to relative insufficiency, not to valvular lesion. One 
of the earliest signs of dilatation is an irregular and intermittent pulse. 

Hypertrophy and dilatation are often due to overexertion and alcohol, 
as in heavy beer drinkers. 

During severe muscular effort, when the heart is strained to its utmost, 
as in mountain climbing, acute dilatation may result. A sense of distress is 




Fig. 116. — Showing the Dulnbss due to Dilatation and Hypertrophy op Both 

Ventricles. 
Apex rounded and apex beat diffused. 

felt and a feeling of dyspnoea, which may pass over after a day's rest or 
may reassert itself on the slightest exertion. We speak of such a person as 
"wind broken." 

Dilatation of the right heart may be recognized by the location of the 
impulse, which is below or to the right of the ensiform cartilage. The apex 
beat may be absent on the left side. Pulsation to the right or left of the 
sternum in the second and third interspace is looked upon as an evidence 
of auricular dilatation. 

The management of circulatory failure due to dilatation of the heart 
will be considered in the chapter on Valvular Heart Disease. 

In acute dilatation from overstrain absolute rest in bed must be enjoined. 

ACUTE CIRCULATORY FAILURE (HEART STRAIN, SHOCK, 
COLLAPSE, RUPTURE) 

A sound and a damaged heart may suffer acutely in various ways, viz. : 
from direct injury, embarrassment due to compressed or rarefied air, entrance 
of air into the right heart, embolism of the pulmonary artery, severe hsemor- 



ACUTE AND CHRONIC ENDOCARDITIS 



339 



rhage, shock or nervous depression, and the various septic and chemical 
poisons, anaesthesia, and mechanical obstruction to the heart's action from 
pericardial effusion. It is nothing unusual for a senile heart to come to a 
stop from shock or from the effects of an operation or from an attack of 
acute gastroenteritis. A sudden heart death in convalescence following 
septic diphtheria is no uncommon circumstance. 

The heart's nourishment depends so much upon its own proper function 
that any depressing circumstance which lowers the blood pressure in the 
aorta and coronary arteries may be of great moment. The rapidity with 
which sudden circulatory fail- 
ure sets in gives the patient 
barely time to state his dis- 
tress; consciousness fails, the 
face turns blue, the extremi- 
ties are cold, the pulse fails, 
and death supervenes some- 
times in a convulsive seizure. 
In subacute cases the collapse 
passes over and the circula- 
tion under proper manage- 
ment gradually improves. 

The treatment of acute 
collapse is its timely preven- 
tion, of which we shall speak 
under the management of the 
various diseases which pro- 
voke it. In cases of acute 
collapse in which death is not 
instantaneous the prompt at- 
tention of the physician may 
save life. Lower the head, 

loosen the clothes, employ ar- Fig. 117.— Rupture of the Heart (Dr. R. H. 

tificial respiration, hold am- Newton), 
monia to the nose, give salt 

water hypodermically or per rectum, or administer strychnine, camphor, 
whiskey, and digitalis internally or hypodermically (see chapter on General 
Therapeutic Management). The gradual progressive insufficiency of the 
heart noticeable in so many diseases is best combated by absolute rest 
and such other measures as are discussed under their various headings. 

ENDOCARDITIS 

Endocarditis is an inflammation of the inner (lining) membrane of the 
heart. Rheumatism or any other infectious disease may constitute the 
causative factor. We distinguish acute and chronic endocarditis. 

ACUTE ENDOCARDITIS 

Acute endocarditis is recognized clinically as simple, malignant, septic, 
and verrucose. The simple form is one of the associated features of acute 




340 



THE CIRCULATORY SYSTEM 



rheumatic fever, and is occasionally met with in scarlet fever, so called 
tonsillitis, typhoid fever, pneumonia, and chorea. 

Bacteria, the causative factor of infection, for some reason or other 
find a foothold on the endocardium, usually in the left heart, and the ensuing 
hyperplastic or destructive inflammatory process is very apt to result in 
permanent damage to the valves of the heart. 

A somewhat similar but much severer form of endocarditis occasionally 
follows gonorrhceal infection or gonorrhoeal rheumatism. The most fatal 
form is septic or ulcerating endocarditis, all forms presenting but different 
degrees of intensity of the same process, but possibly of different microbial 
origin. The lesions are vegetative, ulcerative, or suppurative, and the 
sequelae are embolism and infection of other tissues and organs. 

Diagnosis. — There is nothing characteristic in an onset of endocarditis. 
When in the course of rheumatic arthritis there is an exacerbation of fever, 
with a rapid, unsteady heart, with or without increase of joint symptoms, 
endocarditis may be suspected. If, in addition, a murmur is now heard in 
a heart which was free before, we are very apt to diagnosticate endocarditis, 
bearing in mind, however, that accidental murmurs are heard over the heart 
during febrile disease, but may disappear and leave an intact heart. There 
may be sweating, chills, delirium, petechia?, and embolic processes, with 
the symptoms pertaining to them, such as coma, paralysis, local pain in 
some other organ, bloody sputum, bloody urine, and retinal haemorrhage, 
or localized gangrene. 

Some types of endocarditis, particularly the chronic form, resemble 
irregular intermittent fever. Others have the cardiac or cerebrospinal 
symptoms pronounced. Jaundice has been observed, also oppression and 
short breathing, cardiac pain, and great restlessness. Each case must be 
judged upon its own merits, and no definite general diagnostic landmarks 
are possible. 

The acute septic form, which frequently terminates fatally, may com- 
plicate septicaemia from erysipelas, puerperal fever, and gonorrhoea. The 
milder forms usually recover with a damaged valve. One of the great 
achievements to be hoped for in practical medicine would be the prevention 
of endocarditis in chorea, eruptive and other fevers, gonorrhoea, tonsillitis, 
diphtheria, etc. 

Treatment. — Absolute rest; warm baths; cooling drinks; an ice bag to 
the heart. In the septic form the management is the same as for any 
other sepsis, viz., elimination and stimulation. Treatment by antistrep- 
tococcus serum is in its experimental stage. 

In acute articular rheumatism with high fever, rapid heart, and pro- 
nounced restlessness, it seems rational to combine a heart sedative with 
sodium salicylate as follows: 



1$ Sod. salicyl., 

Potass, iodid., 

Tinct. aconiti radic. 
Tinct. verat. virid., 
Aquae, 





3ij; 

5ss.; 



M. S. : A teaspoonful, with sugar, every two hours, for children; 



PERICARDITIS 



341 



the dose for adults must be larger. Apart from internal medication, 
Crede's ointment may be rubbed into the skin, 3j three times daily. 

It is, furthermore, of the utmost importance that in the treatment of 
rheumatic cases routine flushing of the bowel with warm saline solution 
be practised, in order to eliminate, if possible, the danger of intestinal 
toxaemia or secondary infection from the enteric tract. 

CHRONIC ENDOCARDITIS 

Chronic endocarditis is a slow, insidious process, secondary to acute 
endocarditis or superinduced by various irritants and infections, such as 
syphilis, gout, alcohol, and malaria — together with prolonged muscular 
strain. This process results in thickening and contraction of valves, 
usually in the left heart. It may be observed in children and it is common 
in middle aged individuals. When the valves are affected and the heart's 
equilibrium is disturbed, the first complaints are heard, and subsequently 
the course and management are those of chronic valvular disease. Al- 
coholism, syphilis, malaria, and rheumatic infection are the predisposing 
factors. Syphilis and malaria require specific treatment and change of 
climate. Persons living in unwholesome abodes must be told that sunshine, 
cleanliness, and fresh air are the best preventives against acute and chronic 
infection. 

PERICARDITIS 

Definition and ^Etiology. — Pericarditis is an infection and inflammation 
of the pericardium, usually secondary to an inflammatory process of a 
neighboring serous membrane. As in pleurisy, we have a dry pericarditis 
or one with serous or purulent effusion with and without adhesions. 
Rheumatism, all forms of sepsis, the eruptive fevers, Bright's disease, 
typhoid fever, diabetes, scurvy, and tuberculosis are provocative of peri- 
carditis. 

Pericarditis is not rare in children as a sequel of rheumatism or scarlet 
fever. 

Dry pericarditis is recognized principally by its friction sound, to and 
fro, corresponding to the systole and diastole of the heart. This friction 
sound is superficial and close to the ear, and there are no definite lines of 
transmission, as in endocardial murmurs, although it must be admitted 
that occasionally it is difficult to distinguish a friction sound from a double 
murmur. Dry pericarditis is of limited duration, but it may persist and 
result in a chronic thickening of both layers of the pericardium. There 
is no typical fever curve in this ailment. 

Pericarditis with effusion may develop without characteristic signs, 
although precordial distress, pain on pressure over the heart, and dyspnoea 
are the rational symptoms. Patients so afflicted have an anxious counte- 
nance with a paradoxical pulse, which becomes lost or faint during inspira- 
tion. These symptoms are the direct result of embarrassed heart's action. 
From pressure upon the trachea and oesophagus we may have aphonia, 
cough, dysphagia, and venous stasis. Insomnia, delirium, and coma are 
observed in severe cases. 



342 



THE CIRCULATORY SYSTEM 



The physical signs of massive pericardial effusion are bulging of the chest 
and of the intercostal spaces, occasionally cedema of the chest wall, diminu- 
tion and obliteration of the cardiac shock, dislocation and loss of the apex 
beat, and an irregular, pear-shaped increasing heart dulness, with a broad 
downward base. With absorption of the fluid the friction sounds return. 
When an onset of pericarditis is suspected, the heart dulness should be 
carefully marked with a blue pencil. Pericarditis is often overlooked or 
mistaken for pleurisy. 

The prognosis depends upon the underlying cause and is favorable in 
the simple variety. Septic cases are usually fatal ; the purulent variety 




Fig. 118. — The Triangular Area of Dulness Due to a Large Pericardial Effusion is 
Shown by the Outer Solid Line. 

For comparison the normal cardiac dulness is shown by the inner shaded area. Note position 
of apex beat with reference to the pericardial dulness. 

not necessarily so, as the pus may be absorbed or is amenable to surgical 
interference. 

Differential Points. — It is sometimes extremely difficult to discriminate 
between dilatation of the heart and pericarditis with effusion. Cases occur 
in children in which it is difficult to distinguish between encapsulated pleu- 
ritic effusion and pericarditis and effusion, the needle showing a serosan- 
guinolent fluid. Cases have been reported in which purulent pericarditis 
was mistaken for encapsulated empyema. 

Hydropericardium (Dropsy of the Pericardium) occurs in connection 
with general dropsy and presents the signs of pericarditis with effusion. 
Chylopericardium is a term used in cases of chylous effusion. Hcemoperi- 
cardium may result from rupture of an aneurysm or from injury. Pneumo- 
pericardium may result from a stab wound, etc. 

Treatment of Pericarditis. — A stiff dose of calomel and jalap is appro- 
priate at the start of almost any ailment. Rest in bed should be enforced. 
An ice bag to the heart or a blister or dry cupping is indicated. In adults 
complaining of severe pain a morphine injection over the seat of pain may 
be advisable. Crede's silver ointment (15 per cent of silver to one ounce 



ADHERENT PERICARDIUM 



343 



of fat) may be used to counteract sepsis. It is administered by inunction, 
5j ter in die. 

If syphilis or malaria is suspected as an underlying cause, potassium 
iodide may be administered by the rectum, or a few doses of quinine may 
be given by the mouth. The salicylates are indicated when a rheumatic 
origin is the most plausible. The fewer drugs, the better for the patient. 
Five drops of dilute hydrochloric acid in sweetened water, after eating, 
will aid digestion. The diet must be light with plenty of water. Feverish 
patients generally enjoy a warm bath. In massive effusion, with severe 
pressure symptoms, aspiration may be necessary with subsequent incision 
and drainage if pus or seropus is found. The puncture should be made in 
the fourth or fifth interspace, one to one and a half inches to the left of the 
sternal margin (see article on Dropsy and Effusion). 

Suppurative pericarditis secondary to pleuropneumonia, empyema, 
osteomyelitis, and other septic processes, typhoid fever, influenza, trauma, 
etc., requires surgical treatment. The mortality is about 60 per cent. 
Resection of a portion of the fifth rib under local or general anaesthesia 
is the proper procedure. Puncture is not sufficient. 

ADHERENT PERICARDIUM; CHRONIC ADHERENT PERICARDIUM 

Pericarditis with adhesions which hamper the heart's action. 

Symptoms. — Systolic depression of the intercostal spaces and fixation 
of the apex beat. In adhesions between the pericardium and chest wall 
the area of cardiac dulness remains the same on inspiration and expiration, 
and the heart is usually enlarged. Adherent pericardium may be universal 
or partial, following pericarditis of all forms. The symptoms are indefinite, 
although in children, with their flexible thorax, systolic retraction of the 
apex region with diastolic rebound and diastolic collapse of cervical veins 
is noticed. Accidental blubbering murmurs are also heard and the pulsus 
paradoxus is observed. Adherent pericardium is sometimes associated 
with a systolic retraction in the eighth or ninth interspace on the left side 
posteriorly (Broadbent's sign). 

Treatment. — Nothing in the way of irritating restrictions should be in- 
flicted on the patient. Apart from constitutional treatment nothing can 
be done. 



23 



CHAPTER XII 



THE CIRCULATORY SYSTEM — Continued 

MUSCULAR AND VALVULAR INSUFFICIENCY OF THE 
HEART AND HEART NEUROSES 

Synopsis: Weak and Flabby Heart. — Fat Laden Heart. — Degeneration of the Heart 
Muscle without Valvular Defects: Senile, Gouty, Syphilitic, Fatty, Fibroid Heart, 
Myocarditis with Constant Arrhythmia. — Valvular Heart Disease and Muscular In- 
sufficiency — Heart Neuroses. 

WEAK HEART; CONGE NITALLY SMALL HEART; FLABBY HEART MUSCLE 

It is a well known clinical fact that some individuals have a small heart; 
thus, most people with tuberculosis or tuberculous tendencies have small 
hearts. It goes without saying that persons not afflicted with tuberculosis 
may have a small heart. Such persons look anaemic, are easily tired, and 
have palpitation on slight exertion, particularly if they increase in weight. 
These patients present all the clinical evidence of moderate heart insuffi- 
ciency, and may show a slight puffiness at the ankles. 

The diagnosis is made by exclusion. So called "neurasthenic " heart 
weakness with its long train of symptoms is often nothing more than motor 
weakness. 

Treatment. — An insufficient heart which will stand a strain will improve 
by reason of such strain and increase in motor force; therefore it is the 
duty of the physician to overrule the laziness and indolence of that class 
of patients whose heart symptoms are not due to degenerative processes 
by ordering active exercise. It must be explained to the patient that pal- 
pitation and moderate dyspncea do not contraindicate active exercise. 
This must be particularly impressed upon corpulent women who feel faint, 
dizzy, and languid after exertion and are very prone to accept rest instead 
of motion. It is in this class of cases that graded climbing, outdoor and 
indoor exercise and gymnastics, and a judicious dietary will work wonders. 
The details of such management will be discussed under Fat Laden Heart. 

Weak heart from cardioptosis is described as a relaxation of the elastic 
tissue of the large vessels which allows the heart to prolapse, that is, hang 
much lower in the thorax than normal. This prolapse causes the apex 
beat to appear beyond the nipple line, and makes the lower part of the area 
of relative and absolute heart dulness much wider than normal. The 
pathognomonic sign of the existence of this anomalous condition is the 
absence of heart dulness at the ordinary upper limit of the organ. As the 
result of the cardioptosis such symptoms as respiratory anguish, painful 
344 



THE FAT LADEN HEART.— SPECIMEN DIET IN OBESITY 345 



dyspnoea, and precordial discomfort develop. Some of the cases of angina 
pectoris are said to be due to this condition. The cause is always an hered- 
itary tendency to relaxation of tissues and seems to be a family trait. 
Apart from general tonic management there is no special treatment for such 
a condition. 

THE FAT LADEN HEART (COR ADIPOSUM) 

Fat people frequently present the clinical evidence of heart weakness, 
and in the absence of a murmur, we are apt to diagnosticate "fatty heart." 
In all such cases we must endeavor to distinguish between fatty degenera- 
tion and the fat laden heart of obesity. In obesity and fat laden heart 
much can be done by rational management. Corpulent individuals are 
sluggish in their movements. They have dyspepsia from mechanical 
interference with respiration, later on from true fatty infiltration of the 
heart muscle; the liver becomes large and fatty. (Edema, intertrigo, and 
eczema increase the suffering of the patient. 

Treatment. — The indications for treatment are reduction of the amount 
of food and oxidation of the fat already stored. Persons who have a tendency 
to corpulency should be warned in time. To reduce weight we have the 
Banting, Ebstein, Schwenninger, and Oertel systems (see Nutrition and 
Diet). The latter regulates diet and gives attention to the heart and 
circulation by systematic exercise, and is as follows: 

Oertel recognizes two classes of cases: 1. Corpulency without respira- 
tory and circulatory disturbance. 2. Corpulency with respiratory and 
circulatory disturbance. The oxidation of fat in the body is accomplished 
by massage, exercise in a gymnasium or in the open air, walking, mountain 
climbing, cycling, horseback riding, rowing, using the punching bag, playing 
tennis, etc. Turkish baths may be used, also the purgative waters of 
Carlsbad, Marienbad, Vichy, and Kissengen or their salts. Liquids should 
be restricted and none taken with a meal. Turkish baths and violent 
exercise are contraindicated when the heart is damaged, as in the second 
class of cases. Walking is the best exercise, and climbing must be done 
gradually (terrain cure of Oertel). 

Thyreoid treatment, probably by increasing oxidation, has given good 
results in a number of cases of obesity. From 3 to 5 grains of the dry pow- 
dered gland may be given three times a day. Should palpitation and 
disturbance of the cardiac rhythm supervene, its use must be stopped, 
but dieting and exercise should be continued. 

SPECIMEN DIET IN OBESITY 

A. M. — Six ounces of coffee or tea, 3 ounces of bread. 

Noon. — Eight ounces of meat or fish of any kind, salad, vegetables, 
2 ounces, fruit, 3 to 6 ounces, bread or pudding, 3 ounces; wine for those 
who are accustomed to it, but no beer. 

Evening. — Two eggs, 4 ounces of ham or raw meat, bread, cheese, salad, 
fruit, tea or coffee. 

Water is to be taken between meals. The diet should be generous as 
to variation. The menu should be liberal in quality, but the quantity 



346 



THE CIRCULATORY SYSTEM 



should not exceed 2,000 calories. One should eat one third less than under 
ordinary circumstances and not attempt to reduce fat by a special kind 
of food. The same rule holds good for children. In corpulency with the 
muscles or valves damaged, and as the consequence, congestion in various" 
organs or arteriosclerotic changes, the greatest care must be taken in 
advising exercise. The physician must feel his way, so to say, and not 
force the patient into a regimen which may bring him into danger from 
bursting of a capillary vessel or from acute dilatation of the heart. Good 
common sense will direct the management, which can only be outlined in 
the absence of a specific case. 

The total daily amount of water should be limited to from 36 to 48 
ounces (including tea, coffee, and wine), except in very hot weather, when 
more can be taken. Sweets of all kinds are to be avoided as much as possible. 

CHRONIC DEGENERATION OF THE HEART MUSCLE NOT DUE TO 

VALVULAR DEFECTS 

Various terms are used to designate such condition, viz.: Senile heart, 
gouty heart, syphilitic heart, myocarditis with constant arrhythmia, fatty 
degeneration, fibroid heart, etc. 

Any acute infection, such as diphtheria, typhoid or rheumatic fever, 
scarlatina, etc., may be the starting point of the chronic inflammatory 
process in the heart muscle. Chronic infections, such as syphilis and 
malaria, are causative factors; and gout, diabetes, atheroma, alcoholism, 
pernicious anaemia, chronic intestinal putrefaction, toxaemia, and overwork 
are frequent causes. In fact, any nutritional change which blocks up 
the blood supply of the heart may result in softening and degeneration 
of the heart walls. The chronic form generally supervenes upon sclerosis 
of the coronary arteries. They are terminal arteries, and become blocked 
with a gradual onset. 

Anatomically we observe induration, softening, calcareous, hyaline, 
fatty, and amyloid degeneration with general or localized dilatation. 
Clinically we cannot distinguish one form of degeneration from the other, 
their symptoms being alike. 

Symptoms of Muscular Degeneration of Whatever Nature. — Dyspepsia; 
palpitation; precordial distress; arrhythmia; anginoid, syncopal, apoplectic, 
or epileptoid attacks; a short, unsustained, rapid, or regular or irregular 
pulse; cold extremities; dropsy; and great weakness. The heart eventually 
dilates, and a murmur may be heard, due to ventricular dilatation. Sudden 
death after a full meal is not infrequent. 

The area of the heart dulness may be normal unless degeneration has 
affected a hypertrophic heart. Attacks of aphasia often present themselves 
when sclerosis is present. 

Prognosis. — We cannot cure this condition, but by careful management 
we may prolong life for an indefinite time. A person with myocarditis 
may drop dead suddenly or live for many years. 

THE SENILE HEART AND ARTERIOSCLEROSIS 

In late life and without any history of previous disease the heart is 
often found enlarged, and an active or relative weakness of the myocar- 



VALVULAR HEART DISEASE 



347 



dium is the origin of the symptoms of the senile heart, such as precordial 
anxiety, unstable action, weak impulse, intermission of the beat, subjective 
throbbing (which may be physical or emotional), cardiac asthma with and 
without exertion, tremor cordis, fluttering, loss of appetite, fainting, a 
feeling of weakness, albuminuria, and a feeling of insecurity. 

Senile diseases are always degenerative and tend to abridge the natural 
term of life, and our object is to relieve symptoms and check decadence. 
Senile cardiac failure is based upon impaired metabolism. 

Heart Insufficiency due to Syphilis belongs to the group. There are 
no special pathognomonic symptoms in heart syphilis; early symptoms 
are not pronounced. Its prevention is more readily accomplished than its 
cure. When the usual subjective symptoms bring the patient to the phy- 
sician and anamnestic data point to an underlying syphilis as a causative 
factor of myocardial weakness, an antiluetic regimen must be instituted. 
It is in this class of cases that potassium iodide is powerful for good. As 
the heart's action is increased and depressed by nervous influence, it is 
unwise to worry the patient by keeping him constantly under strict super- 
vision. 

Principles of Treatment of the Various Forms of Chronic Muscular De- 
generation. — The patient must be moderate in eating, drinking, and exercis- 
ing. No special diet is necessary (except in obesity). The food should 
be plain and whatever the patient may like, except Swiss cheese, pork (lean 
ham allowed), roast goose and duck, fatty sausage, pastry, rich dishes, 
hard vegetables, cabbage, sauerkraut, peas, white beans, string beans, and 
lentils. Beer should be forbidden as apt to produce flatulence and in- 
digestion. There should be five hours between meals, and the main meal 
should be in the middle of the day. Fluids should be taken sparingly 
between meals. A little whiskey in water is rather beneficial. Ginger 
ale is a good drink. Five to ten drops of dilute hydrochloric acid in water 
after meals will aid digestion. The patient may rest before and after eating. 
A mild smoke is not objectionable. The bowels should move daily. General 
massage is advisable. Venesection is often of great value. A warm, 
cleansing bath may be taken as often as necessary. Iodide of potassium 
is indicated in syphilitic myocarditis. The indications for heart drugs are 
discussed under Valvular Heart Disease. 

VALVULAR HEART DISEASE 

The heart is liable to functional and structural derangements, many 
of which can be recognized clinically, and among the latter the valvular 
defects play an important role. 

A valvular defect is of accommodative importance. A derangement in 
the mechanism of the cardiac valves places an obstacle in the way of the 
outward flow of blood. To maintain the circulation under these conditions, 
the heart necessarily enlarges by hypertrophy of the myocardium. As a 
sequel and correction of valvular insufficiency or obstruction Nature fur- 
nishes us with compensatory hypertrophy of the heart muscle, but muscular 
degeneration and dilatation manifest themselves earlier in the damaged heart 
than in the strong heart, and shorten the tenure of life. The action of the 



348 



THE CIRCULATORY SYSTEM 



heart is increased and depressed by nervous influence; worry and anxiety 
act unfavorably upon the heart and particularly upon a damaged heart; 
therefore, don't worry the patient by keeping him continually under strict 
supervision and treatment. 

The various valvular defects do not influence or disturb the circulation 
in a like manner, but clinically this is more of prognostic than therapeutic 
import. We have no separate treatment for the individual sets of valves, 
and an exact valve diagnosis cannot always be made, nor is it absolutely 
necessary as regards treatment. Treatment really begins when the hyper- 
trophic heart muscle becomes insufficient and the heart is unable to empty 
itself. 

The estimation of valvular insufficiency or obstruction as a problem 
of hydrostatics is easier than the estimation of the loss of elasticity of muscle 
or the reserve power of the heart. The prognosis as to tenure of life in 
cardiac disease is therefore somewhat uncertain. 

Signs and Symptoms of Valvular Lesions 

Aortic Stenosis. — Systolic murmur in the aortic area at the right 
edge of the sternum, in the second or third space, is transmitted upward 
to the right sternoclavicular articulation or may be heard along the right 
edge of the sternum lower down; occasionally it is accompanied by a thrill, 
particularly if it follows rheumatic fever. Functional systolic murmurs 
in this region are also heard in anaemia, in ancemic individuals convalescent 
from acute illness; in impaired flexibility of a valve without stenosis in middle 
age, and in dilatation of the aorta just above the valves. 

The diagnosis will depend upon the history, the aspect, the age, and 
the absence or presence of concomitant symptoms. A loud murmur in- 
dicates strong ventricular action. In actual obstruction we observe cardiac 
hypertrophy and deranged circulation, and a low and forcible apex beat, 
the pulse wave being long and slow and the pulse small. In actual ob- 
struction of the aortic valve the mitral valve may suffer severe strain and 
become incompetent, which is a downward step in the evolution of the 
disease. 

The prognosis is not so serious as in aortic incompetence, but more 
serious than in mitral incompetence. Sudden death from it is improbable. 

Aortic Incompetence. — A diastolic murmur in the aortic area is some- 
times heard in the third left space and may be conducted downward to the 
apex. There is violent arterial pulsation, particularly in the carotid and 
brachial arteries. Pulsatile reddening of the skin is noticed when a red 
patch on the skin is brought out by friction. Capillary pulsation is also 
noticed from various causes, producing a low tension pulse. The pulse 
is a collapsing water hammer pulse (Corrigan) , and has a peculiar double 
beat. In advanced cases the pulse is irregular and the aortic second 
sound, if looked for over the carotid in the neck, is absent. Concomitant 
stenosis modifies the pulse signs. There will be in addition to hypertrophy, 
dilatation of the left ventricle, with a marked apex beat displaced down- 
ward and to the left and lifting of the chest wall. Other symptoms are 
breathlessness, syncopal attacks, anginal attacks, and precordial pain. 
Sudden death is apt to occur. Mitral regurgitation may coexist. 



SIGNS AND SYMPTOMS OF VALVULAR LESIONS 



349 



Prognosis. — When the lesion is not due to degenerative changes in 
the heart, and the signs and symptoms already enumerated are mild, the 
patient may enjoy life for many years, and much will depend upon age, 
habits, occupation, and the time of life when the lesion was acquired. 

Aortic insufficiency may be due to endocarditis, of syphilitic, rheumatic, 
or malarial origin, and possibly to prolonged strain (athlete's heart). A 
relative insufficiency due to dilatation of the aortic ring is rare. 

Mitral Regurgitation. — There is a systolic murmur at the apex or beyond 
the apex, toward the axilla, often heard at the back of the chest, between 
the scapula and the spine, a portion of the ventricle resting upon the spinal 
column. Occasionally the murmur is heard in the third or fourth space 
in the vertical nipple line. 

Differential Diagnosis. — A systolic aortic murmur is conducted 
toward the apex. A systolic tricuspid murmur, regurgitation, is lost to 
the left of the apex and heard between the apex and the lower end of the 
sternum. Spurious pulmonic murmurs due to compression of the edges 
of the lung by ventricular systole are not audible during expiration. 

The pulse in mitral regurgitation is usually irregular in rhythm and 
force, probably owing to varying pressure during inspiration and expiration. 
When a murmur is present and the first sound persists, the leakage at the 
valve may be slight. A loud murmur means a strong ventricle. A musical 
murmur is sometimes heard. The pulmonic second sound is accentuated, 
and hypertrophic dilatation of the right ventricle follows. The apex 
beat is displaced outward to the left with extension of the area of deep 
dulness. In slight regurgitation maximum symptoms are missing. In 
severe, advanced cases dyspepsia, dyspnoea, dropsy, and liver enlargement 
are present. 

Functional mitral incompetence without valvular disease may result 
from anaemia or acute febrile disease. Mitral murmurs are heard in debility 
and old age. 

Ho3mocardiac murmurs are usually soft and blowing and do not replace 
the first sound. They are not conducted to the axilla or back, and there 
is no displacement of the apex beat. There are exceptions, however. The 
history of the case is important. Temporary regurgitation in acute rheu- 
matic fever is possible and does not invariably indicate valvular lesion. 
A mitral murmur associated with chorea and with antecedent rheumatism 
may be functional and temporary, or organic, and a lengthy observation 
is often necessary to come to a definite conclusion. Mitral regurgitation — 
incompetence — may be established imperceptibly in middle and old age, 
with and without organic valvular alteration. The regurgitation may be 
the same as in anaemia and flabby heart (relative insufficiency) or may 
be due to an enlargement of the auriculoventricular opening from dilatation 
of the ventricle from some form of undue arterial tension. 

Prognosis. — This is the least serious and most amenable to treatment 
of all valvular lesions. Slight regurgitation permits of old age, and women 
may marry. Dropsy, pulmonary and hepatic congestion, and oedema 
come and go. 

Mitral Stenosis. — This is a more serious form of valvular disease, rela- 
tively frequent in women. The murmur is diastolic, the pulse is usually 



350 



THE CIRCULATORY SYSTEM 



of high tension and regular until heart failure sets in, the heart is enlarged, 
and the apex beat is displaced to the left and downward in pronounced 
cases with powerful shock and thrill. The pulmonic second sound is 
accentuated from back pressure. Three stages may be observed in the 
evolution of mitral stenosis. In the first stage a diastolic murmur and 
diastolic sound are heard at the apex; in this stage no serious symptoms 
are observed. In the second stage the diastolic sound has disappeared 
and is replaced by a diastolic murmur. This is best distinguished from 
the systolic murmur of incompetence by feeling for the heart shock at the 
time of auscultation. A murmur synchronous with the heart impulse is 
systolic. If we listen at the heart during an attack of palpitation or tachy- 
cardia, all murmurs are indistinct, but reappear after the heart is quieted. 
In the third stage the diastolic murmur frequently disappears, and an exact 
diagnosis may be difficult. Other symptoms are breathlessness on exertion, 
dyspeptic symptoms and nausea with a tendency to congestion of the 
lungs, haemoptysis and arterial embolism, and enlargement and pulsation 
of the liver. When decompensation sets in, in combined stenosis and 
regurgitation, the signs above mentioned fluctuate and the heart's action 
becomes irregular. 

Prognosis. — When mitral stenosis is established in childhood, the prog- 
nosis is more serious than when it is established at a later stage. When 
attacks of delirium cordis, or tachycardia, supervene in mitral stenosis, 
the patient's life is in great danger from acute pulmonary oedema. A 
marked case of this kind in the experience of the writer occurred in a young 
lady of twenty-four whose valvular lesion was acquired at the age of six 
during an attack of articular rheumatism. Without premonitory symptoms, 
" heart hurry " would manifest itself usually in the evening or after retiring. 
Within a short space of time rales could be heard all over the chest, a short 
cough set in, the dyspnoea became acute, foam issued from the mouth, 
and finally the patient became blue from carbonic acid intoxication and 
lay moaning in a stupor. The patient recovered from seven such attacks. 

When several valves are affected all sounds may disappear. 

Valvular lesions in children present no special difficulty in diagnosis. 
Dyspnoea on exertion, ansemia, a bluish tinge of the skin and mucosa, 
clubbed fingers in advanced cases, all forms of dropsy, and congestive symp- 
toms are found — headache, loss of appetite, liability to bronchitis, and 
bulging praBcordia. 

Tricuspid Incompetence and Stenosis, when pronounced, are usually 
congenital. 

Tricuspid Regurgitation, with or without a murmur, is usually due 
to back pressure in the lungs in valvular disease of the left ventricle. The 
murmur, if present, is systolic and heard to the left of the sternum in the 
vertical nipple line. It is often mistaken for a mitral regurgitant murmur. 
The veins of the neck are distended and pulsate, and the damming back of 
the blood in the vena cava inferior enlarges the liver to a point of pulsation. 

Tricuspid Stenosis is usually associated with mitral stenosis. The 
rational physical sign is a diastolic murmur in the tricuspid area, with dis- 
tention of the jugular veins and no pulsation. Dropsy occurs at an early 
period. This condition may be mistaken for mitral stenosis, 



SIGNS AND SYMPTOMS OF VALVULAR LESIONS 



351 



Pulmonic Stenosis is congenital and often associated with a patent 
foramen ovale and perforated interventricular septum. The murmur is 
in the 'pulmonic area and systolic, but such systolic pulmonary murmurs 
are also heard without change in the orifice and valves, viz. : in anaemia. 
A systolic murmur in the pulmonary area is occasionally heard in young 
adults with no other evidence of heart trouble. It is supposed to be due 
to incomplete covering of the conus arteriosus by the overlapping lung, 
so that during systole the conus is flattened out against the chest wall, 
forming an eddy in the blood current and thus giving rise to a murmur. 
Other congenital malformations are incomplete interventricular septa, patent 
foramen ovale, persistence of patent ductus arteriosus, transposition of the pul- 
monary artery and aorta, and malformation of the valves. Children and infants 
suffering from such malformations are fretful, may have convulsions, do 
not sleep, have clubbed fingers and toes, are anaemic or cyanotic, remain 
backward in growth and intelligence, and may or may not have murmurs. 

Diagnosis and Prognosis of Congenital Heart Disease 

With a diagnosis of congenital heart disease the prognosis is that many 
die at an early age or of intercurrent disease; some reach eleven, fifteen, or 
twenty-four years (see Paediatrics) . 

Summary of Diagnosis and Prognosis. — The statement will bear reitera- 
tion that a cardiac murmur does not constitute a heart lesion. There are ac- 
cidental and functional murmurs persisting through long life and accidental 
murmurs which appear during a period of relative incompetency in flabby, 
anaemic, neurotic, and fatty subjects or overworked hearts and disappear 
when the heart has regained sufficient tone. A functional intraventricular 
murmur is systolic in time, half way between the apex and the base. It 
is not anaemic and not heard in the neck, and it is due to cardiac debility; 
that is, the papillary muscles fail to contract in unison with the walls of 
the ventricles. It presents no post mortem lesion and frequently disappears. 

When a valvular lesion is strongly suspected and its exact location is 
doubtful, no anxiety need be felt by the medical man as regards its precise 
rational treatment, for it is practically the same in all valvular lesions. 
With an apex beat in normal position and of normal rhythm, no anxiety 
need be felt regarding a murmur. The cure of a heart lesion should not be 
set down as hopeless until iodide of potassium has been tried. 

Regarding prognosis, each case must be judged on its own merits. 
Small people bear a valvular lesion better than tall and bulky persons, and 
women better than men. Worry aggravates all heart cases, also damp living 
apartments and poverty. Marriage should not be interdicted except in severe 
forms of heart disease. During parturition women often present various con- 
gestive symptoms which pass off after the termination of pregnancy, and 
twenty years of happy married life are better than thirty years of celibacy. It 
is well, however, to warn such patients of the danger of repeated pregnancies. 

Principles of Treatment 

As soon as the diagnosis of valvular heart disease is established, the 
following considerations come up: No dancing for children, except square 
dancing. Rest in bed for choreatic children with murmurs. Sunshine and 



352 



THE CIRCULATORY SYSTEM 



good air for rheumatics, no damp living rooms, removal from malarious 
regions. 

The clinical course of valvular heart disease admits of a division into 
three stages. The attainment of compensation, full compensation, and loss 
of compensation. The treatment of such symptoms as arise during the 
three stages is practically the same for all varieties of valvular defects. Until 
compensation is attained the patient will complain of palpitation, occasional 
nausea, short breath, and nervousness. Heart drugs are not indicated at 
this stage. The patient must lead a quiet and orderly life and avoid worry 
and overstrain. Young men should be advised to enter some field of use- 
fulness in harmony with their "weak heart." Severe exercise, such as 
swimming and violent dancing, should be interdicted. The school work 
should be less exacting than for the healthy; girls should rest one or two 
days during menstruation; cool and cold sponge baths are advisable. In 
the way of exercise walking is advisable; moderate bicycle exercise on level 
ground is permissible. Alcohol, coffee, tea, and articles of food apt to pro- 
duce flatulence, such as beans, peas, lentils, doughnuts, rich pastry, and 
Swiss cheese, should be avoided. A narrow diet is not called for. All 
meats may be eaten except pork, all salads except mayonnaise salads, all 
cereals, eggs, ham, fruit, and stale bread; water, mineral water, and ginger 
ale are to be allowed. The stomach should not be overloaded with food 
or liquids. The bowels should move once a day, or an enema of soap 
water should be given before the patient goes to bed, occasionally a laxative 
or brisk purge. Maltine with cascara for children is indicated. Ten grains 
of blue mass followed by a Seidlitz powder for adults, once a week, may be 
taken. The underclothing should be of thin wool or linen mesh. Protec- 
tion from cold is best secured by thick outer coats and wraps. 

To aid digestion, 5 drops of hydrochloric acid in sugar water may be 
taken after each meal, or Horsford's acid phosphate in water. Patients 
should be warned against great altitudes and Turkish or Russian baths. 
Long sea voyages are not well borne by damaged hearts. The utmost care 
should be exercised not to contract typhoid fever from contaminated water 
and other sources. Typhoid fever and pneumonia give an unfavorable 
prognosis in patients with weak hearts. Anaesthesia in cases of weak heart 
should be carefully considered. The danger of obesity from indolence and 
overeating should be discussed with the patient. Tobacco in moderation 
is not always harmful, and the author knows of a number of patients, 
including physicians, whose rapid heart quieted down after a mild smoke 
and who attained an age of fifty to sixty with mitral insufficiency persist- 
ing for from twenty to twenty-five years. 

When compensation is broken, as shown by marked dyspnoea, dilated 
heart, irregularity of action, and oedema, the treatment may require cold 
baths,' carbonic acid baths, rest in bed with massage and passive motion, 
depletion by the bowels, or venesection when respiration is markedly em- 
barrassed and compression of the upper arm shows the veins standing out 
like whip cords. 

Venesection. — A roller bandage is tightly placed around the arm below 
the shoulder, and the skin over the median vein is disinfected and made 
anaesthetic by injecting a weak cocaine solution. The skin over the vein 



PRINCIPLES OF TREATMENT IN VALVULAR LESIONS 353 



is incised for about an inch, and two catgut ligatures are insinuated under- 
neath the bulging vein. The proximal ligature is tied and the bulging- 
vein is then opened; after from six to sixteen ounces of blood have come 
away, the distal ligature is tied and an antiseptic dressing applied to the 
wound. Venesection is often a life saving procedure which is too little 
practised in our days. 

Carbonated Baths as they are given at Bad Nauheim appear to exert 
a beneficial influence on the circulation by slightly stimulating the skin. 
Such baths can be given in the house by making use of lumps of chemicals 
that generate carbon dioxide, or better still, by aerating the bath water 
with carbon dioxide by means of liquid carbon dioxide from a cylinder, 
now obtainable in all large cities and many country districts, as it is largely 
used in drawing beer from the cask.* Mild, general massage, practised 
several times a week, together with passive motion, is a better aid to the 
embarrassed circulation than any form of bath; of course massage can be 
employed in connection with hydrotherapeutics. 

This bath treatment is carried on for from five to six weeks with an in- 
termission once or twice a week. The temperature of the bath is to be about 
95° F. in the first week, and may be as low as 80° F. in the sixth week. The 
baths are brine baths, 2 pounds of sea salt to 50 gallons of water, gradually 
increasing in strength to 10 pounds of sea salt to 50 gallons of water. The 
gas generating chemicals are placed in the bottom of the tub of warm brine. 

Resisted Movements and Carbonated Baths are combined in the treat- 
ment of heart insufficiency as follows: 

The patient makes regular voluntary movements, which are resisted by 
the physician or operator. These movements are quite gentle, and if there 
should be any weariness on the part of the patient, or his breathing gets to 
be rapid, an intermission is given until the equilibrium of respiration or 
pulse is restored. 

The movements are simply flexion, extension, adduction, abduction, and 
rotation of the limbs, neck, and trunk. As a rule, these exercises improve 
both the heart and the circulation. 

Another form of bath for improving the circulation is as follows: The 
patient remains for ten minutes in a tub half filled with lukewarm to cool 
water, in which he moves about gently. This is followed by douching with a 
pailful of cold water, after which the patient is quickly dried and rests on a 
couch for half an hour and then takes a light breakfast and a leisurely walk. 
The careful climbing of moderate elevations is beneficial in the early stage of 
valvular lesions, but mountain climbing is decidedly injurious. 

Where moderate exercise, baths, proper diet, and massage, with the 
occasional administration of ten grains each of calomel and jalap or other 
laxatives, fail to quiet the heart or to aid it in accomplishing its work, we 
are compelled to make use of drugs. 

The symptomatic management of heart cases after all physical and sim- 
ple methods have been tried is as follows: 

For palpitation in the first and second stage of valvular disease with a 
strong heart muscle apply an ice bag to the heart, and give sodium bromide. 



* Also sold in small metal capsules. 



354 



THE CIRCULATORY SYSTEM 



gr. x to xxx, once or twice a day. Prescribe moderate exercise, a cold 
sponge bath, and tincture of aconite in two drop doses several times a day. 

Palpitation in the third stage, with heart dilatation and dropsy, requires 
venesection and stimulating treatment with digitalis, strychnine, or opium. 
(See chapter on Dropsy.) 

Nausea is a distressing symptom in circulatory failure for which we 
may administer dilute hydrochloric acid in 5 drop doses after eating, or 
Horsford's acid phosphate, 30 drops in water, after eating. In some cases a 
tablespoonful of coca wine after a meal does well. 

Anosmia is a prominent feature in many cases of cardiac disease. The 
patient should live out of doors as much as possible and bromo mangan in 
teaspoonful doses twice a day may be taken, or the following prescription: 

Py Acid arsenicos, gr. ij ; 

Ext. digitalis, 

Ext. mix vomica, 
M. f . Pil. No. 60. 
S.: One pill three times a day. 

For hepatic congestion order rest in bed and give 

Py Podophyllini, gr- i; 

Calomel, gr. x; 

Pulv. aromat., gr. ij. 

In one dose for an adult followed by venesection and digitalis if necessary. 

For pulmonary congestion : 

Py Pulv. digitalis, gr. j to ij ; 

Camphorge, gr. j toij; 

Acid benzoic, gr. ij to v, in wafer. 

Give one such dose three times a day (for adults). 



aa, 3j. 



Or 
Or 
Or 
Or 



Infusion of digitalis in tablespoonful doses four times a day. 
Potassium iodide, gr. x to xx, twice a day in water per rectum. 
Strychnine nitrate, gr. -g^, three times a day. 



Nitroglycerin, gr. r ^ u , three times a day. 
For the management of Dropsy, see chapter on Dropsy. 
In cardiac dyspnosa we may administer : 

Py Morphii sulfur, gr. J ; 

Tinct. strophant., gtt. vj : 

Spir. frumenti, 3j- 

Sie.: Give in one dose. 



Or 



Py Ext. digitalis fluid, 
Tinct. opii, 



aa, 5ij- 



Sig. : Two to four drops every three hours. 



VISCERAL NEURALGIAS IN HEART DISEASE 



355 



Iodide of ethyl may be given by inhalation, dose, 30 drops. 
Atropine sulphate, gr. -g-^, may be given subcutaneously. 



Or 



Spartein sulphate, 



• ■ • gr- H; 
. . . gr. xv; 
ad, §ij. 



Ext. digitalis fluid, 



Aquae, 



Sig. : A teaspoonful every two hours. 



In insomnia we give 

1$ Hydrate chloral, ) 
Sodium bromide, J 



gr. x to xx, at bedtime. 



Or 



Codeine, 

Urethane, 

One dose at bedtime. 



gr- j to ij ; 



dr. ss. 



Or 



Hyoscine 



Or 



Sulphate of morphine hypodermically, gr. J to \. 



In Acute Pulmonary QZdema and Collapse : 

Camphor oil subcutaneously, 15 grains to 5jv of oil, dose 15 drops 
every three to four hours. 

Digitalis in whiskey subcutaneously. 



Benzoate of sodium and caffeine, gr. ij to v subcutaneously, every three 
hours. 

Continuous Digitalis Treatment. — When that period arrives in 
which we are no longer able to produce a lasting compensation by rest, 
dieting, baths, massage, and short courses of medicine, we may make life 
more comfortable by administering digitalis (four to eight grains of the 
powdered leaf) on one day once a week, with strychnine and opium between 
or in combination. 

Visceral Neuralgias in Heart Disease Simulating Other Disease 

Hepatic congestion with pain or tenderness in the liver and visceral 
neuralgias in the intestines and spleen simulate local trouble, such as 
hepatic abscess, appendicitis, or tubal disease. Valvular heart lesions are 
sometimes associated with excessive menstrual flow, and sometimes with 
amenorrhcea. Women with heart disease, endometritis, and metrorrhagia 
combined have suffered serious operations for supposed malignant disease 
when a mild curettage and a few doses of digitalis or strychnine and opium 
would have sufficed to make them comfortable. 

The management of heart disease in children is practically the same as 
in adults. The dose of drugs must be reduced one quarter or one third. 



1$ Ext. digit, fluid, 

Spir. frumenti, 

Fifteen drops every four hours. 



• • • 5j; 
ad, 3jv. 



356 



THE CIRCULATORY SYSTEM 



Res ume 

We find practically three groups in cardiac therapeutics: Cases in 
which no special treatment is required, cases in which excessive growth 
and strong action call for aconite or veratrum viride, the bromides, etc., and 
other sedatives, and cases in which the heart falters and needs support, 
and for which digitalis, used differently according to varying indications, 
is the principal remedy. 

This line of treatment is held to independently of the exact valve which 
may be affected. 

In functional valvular disorders the treatment is by rest, graduated 
exercise, rational diet, and hydrotherapy. 

In heart neurasthenia we advise active exercise, rational diet, and fortify- 
ing baths. Where heart disease has been known to exist for several genera- 
tions in a family, it is important that the children should be protected, as 
far as possible, from even the minor infectious diseases. So mild an infection 
as mumps has been known to cause a serious heart lesion in such susceptible 
individuals. 

NEUROSES OF THE HEART 

Disturbances of presumably neurotic origin, independent of central 
nervous disease or valvular lesions, are very common. For all such neuroses 
we have special clinical terms, and we speak of palpitation, arrhythmia, 
tachycardia (delirium cordis), bradycardia, and anginal attacks. The source 
of such clinical phenomena is not readily located. Palpitation and arrhyth- 
mia may be perceptible to the patient or only an objective symptom, par- 
ticularly at times when there is an increased excitability of the nervous 
system, at puberty and the climacterium and at the time of menstruation. 
Heart palpitation may set in suddenly from fright and emotion (fire, fear 
of death, dreams), lasting all the way from a single attack to recurrent 
daily attacks, extending over one to three years. In neurasthenics the 
slightest cause will send the heart up to 150 beats, with a feeling of "gone- 
ness," dyspnoea, and a pallid countenance. On the other hand, arrhythmia 
may disappear after exertion even in valvular lesions. 

In all obscure neuroses of the heart which apparently do not improve 
by diet and by physical methods of treatment the patient should receive 
the benefit of the doubt and undergo a mild course of antisyphilitic or anti- 
malarial treatment. 

Simple Palpitation 

In simple palpitation the examination of the heart is usually negative. 
In neurasthenics and ansemics a murmur is frequently heard. 

Prognosis. — The prognosis in simple palpitation is good. Occasionally a 
patient with what is thought to be simple palpitation will develop some 
organic heart lesion. 

Treatment of Simple Palpitation. — The patient must be told that he 
has simply a nervous heart and that the exercise of will power will overcome 
nervousness. The bowels should move once a day, and dilute hydrochloric 
acid (gtt. v to x) may be given in water once a day to aid digestion. The 



ARRHYTHMIA OF THE HEART 



357 



diet should be liberal, but the following articles should be avoided: Beans, 
mayonnaise dressing, fried oysters or fried fish, and anything apt to produce 
flatulence. Alcohol, tea, coffee, and tobacco usually aggravate the neurotic 
heart to palpitation, but there are exceptions to this rule, and the wise 
physician will individualize regarding such restrictions. 

Cool sponge baths, cold to the heart region, massage, walking, bicycling, 
punching bag exercise, and horseback riding are indicated, also moderate 
up-hill walking, a change of scene, comedy, and light literature for the 
morbid. Static electricity and vibration treatment (see Chronic Constipa- 
tion) will aid in overcoming palpitation, and women with a lax abdomen 
and some degree of organ displacement (enteroptosis) should wear a support 
or binder. 

In the way of drugs, bromide of sodium may be given in ten to thirty 
grain doses twice a day. The underlying cause of palpitation, be it obesity 
or indigestion or neurasthenia or anaemia or exophthalmic goitre or brain 
disease or cardiac or renal insufficiency or respiratory insufficiency or 
sexual excitement, must be investigated. When we have a clear picture 
of simple neurotic palpitation or palpitation symptomatic with reference to 
other complaints, we shall know how to treat it. 

Arrhythmia 0} the Heart 

We find disturbance of rhythm from many causes, e. g., from organic 
heart disease and from the abuse of tobacco, coffee, tea, alcohol, and digitalis. 
We find it in chlorosis, in syphilis and malaria, in gastrointestinal putrefac- 
tion, in intestinal, hepatic, or renal colic, in urogenital ailments, in disease 
of the brain and cord or of the cardiac plexus, and from great mental worry 
or great fatigue. Most neurasthenic individuals have an irritable heart. 

Arrhythmia of the heart may occur normally as an expression of the 
influence of respiration upon the heart (in sleeping children). The dropping 
of a beat is common in cases of senile heart, coffee heart, and tobacco heart, 
and particularly in cases of heart muscle degeneration. The fcetal heart 
rhythm is indicative of dilatation of the heart. Tremor cordis (fluttering 
of the heart) and gallop rhythm occur in arteriosclerosis. Thus, we may 
have temporary or transient and, habitual arrhythmia which is described 
by the patient as a sudden spasm giving rise to a disagreeable sensation. 

The significance of arrhythmia is occasionally difficult to determine 
and depends entirely on the underlying cause. It may persist for many 
years in individuals who are apparently in fair health. Arrhythmia may 
be true and false. In the former the heart beat is actually dropped, in the 
latter the heart beat is regular, but the pulse is dropped. 

Treatment of Arrhythmia. — Digitalis is not indicated in simple arrhythmia 
without dropsy. We treat or remove the underlying cause if it can be 
found. In arrhythmia and slow heart following infectious disease, camphor, 
ether, strychnine, and other stimulants are to be administered. 

In the arrhythmia of old age the heart will want stimulants, such as al- 
cohol, strychnine, and opium. The patient should rest after eating, and 
should eat a little at a time and frequently. Moderate exercise, country life, 
avoidance of worry, occupation of the mind, reading, and playing cards and 



358 



THE CIRCULATORY SYSTEM 



other games are to be recommended. In painful arrhythmia, strophanthus 
is suitable. 

In serious forms of arrhythmia depending upon organic heart disease 
or valvular or muscular insufficiency or upon some unknown permanent 
disturbance of heart innervation, the treatment will be stimulating, sedative, 
or specific, as the case may be. The bowels must be kept free, the skin 
active, and the tongue clean. If syphilis cannot be excluded, potassium 
iodide per rectum is indicated. Warburg's tincture or arsenic is called 
for in suitable cases. 

Tachycardia {Paroxysmal Rapid Heart) 

In paroxysmal rapid heart, or tachycardia, the attacks come suddenly 
in hearts apparently sound as well as in damaged hearts. Alcoholics are 
subject to tachycardia, also the offspring of alcoholic parents. 

In typical cases the heart's action is so rapid that the pulse cannot be 
counted. The temperature in the attack is usually normal, and the patient 
is pale and of an anxious expression and unwilling to lie down on account 
of dyspnoea; some are able to be up and about. 

Treatment. — Apply cold to the region of the heart and give bromide of 
sodium (5j) internally or morphine (gr. \ to \) subcutaneously, or ethereal 
tincture of valerian, in twenty drop doses, and subsequently pay attention 
to any discernible underlying cause. During the attack there is usually con- 
siderable flatus, which can be relieved by the rectal tube. After the termi- 
nation of an attack we should endeavor to elicit and treat the underlying 
cause. In the intervals of attacks hydrotherapeutic management should 
be faithfully carried out. 

Bradycardia 

Bradycardia, or slow heart, may be pathological or normal. Some in- 
dividuals have a very slow heart's action. It is seen in the puerperal 
state, in convalescence from infectious disease, probably from exhaustion, 
in cachexia, jaundice, cholsemia, fainting spells, in aneemia, diabetes, sea- 
sickness, poisoning from opium, fibroids of the uterus, disease of the central 
nervous system, sunstroke and heat stroke, exhaustion, and hunger. Strain- 
ing at stool gives rise to a slow pulse, as does cervical injury and occasionally 
an epileptic seizure. 

Symptoms. — The symptoms vary with the underlying cause. 

Treatment. — Treatment is directed to the underlying cause and is stimu- 
lating. If it is from exhaustion or nerve poisoning, following infectious 
disease, absolute rest, mild general massage, strychnine, camphor, ether, 
and artificial warmth are indicated. 

Spurious Angina Pectoris 

Hysterical angina is a common ailment in neurotic girls and women. 
They complain of a sensation of deadness and stiffness and have pains in 
the back and neck. 

Treatment. — The attack is best cut short by loosening constricting 
clothes and administering ammonia by the nose and the ethereal tincture of 
valerian (gtt. xx) internally in water. Judicious management of an under- 
lying neurasthenic condition will improve and cure the patient. 



DISEASES OF THE ARTERIES AND VEINS 



359 



Angina Pectoris 

This form of circulatory disturbance is supposed to be due to imperfect 
cardiac nutrition and changes in the coronary arteries, and gives a grave 
prognosis. The pain of true angina is agonizing and extends into the neck 
and arms, with great fear of death. It occurs mostly in adults in con- 
nection with other clinical evidence of disease in the heart or vessels. The 
face is ashy, the patient has a cold sweat, the pulse may be regular or 
irregular, and the pain may last up to a minute or two. The patient is 
exhausted for some time after the attack. Attacks may recur at long or 
short intervals and may end in death. 

A mild true angina is noticed in valvular disease. There is a sensation 
of deadness and stiffness — cold and pain in the back and neck. As a rule 
there is no pain in heart disease; angina makes the exception. The patient 
is afraid to move or breathe. At the end of the paroxysm there is flatulence, 
with eructations and a desire to urinate. True angina appears to have no 
connection with defects of the mitral valve and is more symptomatic of 
fatty muscular degeneration, heart syphilis, and arteriosclerosis. The state 
of the heart during a paroxysm is not known. The pain comes on during 
exertion. 

Differential Points. — We must distinguish angina pectoris from the pain 
of aortic aneurysm, pericarditis, and pleurisy, and from pain over the heart 
in a hypersesthetic area and pain in the intercostal muscles. 

Treatment. — A person subject to attacks of angina pectoris must lead 
a quiet life, avoiding excitement and overexertion, and should always sleep 
in a cool room. A dose of laxative medicine should be taken once a week 
at least, and five drops of hydrochloric acid may be taken after eating. 
In the way of diet the patient should avoid beans, pork, rich dressings, 
dense cheese, pastry, and fried sea food. In the attack the patient may 
have internally from 10 to 20 drops of Hoffmann's anodyne or compound 
tincture of valerian or 5 to 10 drops of chloroform on cracked ice. A hypo- 
dermic injection of morphine, } of a grain, with atropine, tto of a grain, 
may be indicated. Inhalations of amyl nitrite, gtt. 2 to 5, or sulphide 
of ethyl, gtt. 20 to 30, often give relief. 

If the heart is weak after an attack, the patient must rest in bed and 
also rest after eating. 

Should syphilis, malaria, anaemia, gout, etc., be suspected as the under- 
lying cause, the proper management must be inaugurated. General massage 
is helpful in all circulatory disturbances, and bromide of potassium subdues 
nervous irritability. 

DISEASES OF THE ARTERIES AND VEINS 
ARTERIOSCLEROSIS; PHLEBITIS; VARICOSE VEINS; 

ANEURYSM 

GENERAL REMARKS 

Auscultatory phenomena in blood vessels are unsatisfactory. When 
arterial pressure from any cause whatsoever is permanently increased, 
there is danger of lupture of capillaries with its direct sequela?, particularly 
24 



360 



THE CIRCULATORY SYSTEM 



in arteriosclerosis. Arteriosclerosis affecting the coronary artery is a serious 
damage as regards the nourishment and work of the heart itself. We may 
have acute arteriospasm, as in strychnine, lead poisoning and malaria and 
acute dilatation of vessels, as in shock, in which the body bleeds into its 
own vessels. Vasomotor paralysis from alcohol, chloral, and infusion of 
digitalis is often confounded with heart collapse. 

The venous circulation may be influenced by the force of the heart's 
action, or by any obstruction to the circulation, disturbance of lung func- 
tion, pressure of exudates and tumors, pericardial exudates, and pressure 
on the inferior and superior vena cava, leading eventually to death. 

The pulse varies in various individuals and may be normal anywhere 
from 50 to 100. Children have a rapid pulse on examination and their 
pulse is frequently irregular even in sleep. 

ARTERIOSCLEROSIS (ATHEROMA) 

This is a chronic inflammatory or degenerative process in the intima, 
resulting in rigidity of the blood vessels. It naturally accompanies old 
age, and hence the saying: A man is as old as his arteries, or in other words 
he may be old at forty. It is often hereditary and has rheumatism, gout, 
syphilis, lead poisoning, alcoholism, malaria, chronic intestinal putrefaction, 
or high living as an underlying cause, and is frequently associated with 
heart and kidney disease. It is diffuse or localized in any organ or tissue. 
It is the underlying cause of organic nutritional changes in organs. Bright 's 
disease, organic heart disease, hepatic disease, aneurysm, haemorrhage, and 
apoplexy often have their origin in vascular degeneration. 

Symptoms of Pronounced Cases. — A hard, high tension pulse, hyper- 
trophy of the heart, dyspnoea, capillary haemorrhage in the brain with 
transient aphasia, hemiplegia, thrombi, gangrene, and insomnia. Arterio- 
scleroris is not common before the age of forty, and is very rare in children. 

Treatment. — In the early stage the patient must be told his condition 
with a view of securing his cooperation in changing faulty habits. Medica- 
tion is not beneficial in the early stages unless syphilis or malaria is present. 
The skin and bowels must be kept active. As a rule, alcohol is prohibited, 
and a change from city to country life, and vice versa, is beneficial. Mild 
massage and daily exercise are beneficial. Good water may be taken ad 
libitum. 

Diet. — There should be about five hours between meals. The meals 
should be dry; liquids may be taken between meals. 

Specimen diet: Cereals, fish, meats sparingly, ham, eggs, tongue, toast, 
crackers, salads, onions, milk, coffee, tea, ginger ale, Vichy, hot water, 
cocoa, and one ounce of whiskey a day. Large meat consumers may adopt 
a vegetarian diet for a time with benefit to themselves. (See Nutrition.) 

Medication. — When syphilis or malaria is suspected as an underlying 
condition, potassium iodide or Warburg's tincture may be given for a 
time, or calomel (gr. j) three times a day for three days, and occasionally 
repeated. For dyspnoea, venesection, nitrite of amyl, tincture of aconite 
(gtt. ij to x), belladonna or atropine, or morphine (gr. \ subcutaneously) is 
to be employed. 



VARICOSE VEINS 



361 



In Insomnia with Dyspnoea, we may try in addition cannabis indica, gr. 
-V at bedtime; hyoscine, gr. T > u at bedtime; or nitroglycerin, gr. yj^ to 
5 V three times a day. 

1$ Codein., gr. j; 

Urethan., gr. xxx. 

M. Sig. : Take at bedtime. 

When the urine is scanty we administer diuretin, gr. xv five times a day, 
and other diuretics. (See also Senile Heart.) 

PHLEBITIS (INFLAMMATION OF VEINS) 

This may be simple or septic and spreading. The simple variety may 
terminate in resolution or turn into an abscess. 

Symptoms. — The superficial veins are hard and tender to the touch 
(thrombosis) and surrounded by red inflamed tissue or by collateral oedema. 
Gout and syphilis are frequently underlying causes; injury and undue 
pressure are exciting causes. 

Treatment. — Rest, elevation of the limb, cold lead lotion applied by 
compress, an ice bag to the inflamed region, free catharsis, and light diet. 
If suppuration is evident, a free incision is indicated. 

Venous thrombosis (marastic) is observed in all forms of cachexia as a 
complication. 

The septic, or spreading, variety of phlebitis is a dangerous malady accord- 
ing to its location. Thus, in sinus phlebitis following otitis media or mastoid 
operations or in septic phlebitis of the pelvis following childbirth the prog- 
nosis is grave. Phlebitis of this nature may terminate in fatal embolic 
pyemia. The treatment is symptomatic and surgical. 

VARICOSE VEINS 

Varicose veins are common in the rectum (haemorrhoids), the scrotum 
(varicocele), and the lower extremities. The varicose condition is due to 
increased venous pressure and changes in the walls of the vessel. Haemor- 
rhoids and haematocele of the scrotum will be discussed elsewhere. 

Varicosities in the lower extremities produce fatigue, cramp, swelling, 
pain, and numbness in the affected limb. Occasionally a vein ruptures 
and a brisk haemorrhage follows, which is readily controlled by compression. 
Venous thrombosis may set in and the whole leg become cedematous and 
inflamed. Venous thrombosis is a frequent complication in cachexia from 
any cause. 

Treatment. — For simple varicosities we order a daily morning dose of 
salts in warm water, and advise the patient to wear an elastic stocking or 
apply a rubber bandage three inches wide and five yards long from the toes 
up, over a thin long stocking with the toe end cut away. If inflammation 
sets in, and the vein becomes hard and painful, the limb must be elevated 
and cold lead water applied for a day or two. In very obstinate cases a 
radical cure by ligation and incision or excision may be attempted. 



362 



THE CIRCULATORY SYSTEM 



ANEURYSM 

An aneurysm is a blood tumor having for its walls a dilated artery or 
communicating with an artery. It is formed by the yielding of one or more 
of the coats of a blood vessel in consequence of injury or strain or from 
tissue degeneration, as we find it in alcoholic or syphilitic individuals or 
in those suffering from arteriosclerosis to such an extent that the artery 
does not stand blood pressure. Embolism of a blood vessel with subsequent 
inflammatory changes and weakening of the arterial wall beyond the embolus 
is another cause of aneurysm. 

The exact structure of an aneurysm cannot be made out by an external 
examination. The form and size can be approximately determined by 

palpation and percussion, etc. We 
speak of a fusiform, sacculated, and 
dissecting aneurysm. 

Symptoms. — Pain and pulsating 
and expansile swelling. The pulse is 
delayed and diminished in force on 
the diseased side. A murmur may 
or may not exist. 

Pressure effects are erosion of bone, 
enlargement of superficial veins, local 
oedema, nerve paralysis, husky voice 
and aphonia from pressure paralysis 
on recurrent nerve, and dysphagia and 
dyspnoea from obstruction of the oeso- 
phagus and trachea, according to lo- 
cation. 

An aneurysm may rupture suddenly 
or leak into the surrounding tissue or 
undergo spontaneous cure, in which 
Fig. 119.— Aortic Aneurysm. event there is usually a decrease of pul- 

sation and of the size of the swelling. 
Differential Diagnosis. — In an abscess or tumor over an artery the pulsa- 
tion is not expansile and the swelling is not influenced on compressing the 
artery above. A carotid aneurysm may be distinguished from an enlarged 
thyreoid gland by the gland moving with the larynx in swallowing. When 
the physical signs are not conclusive, an exploratory needle puncture may 
be made. 

Aneurysm of the Aortic Arch 

The accompanying picture shows the external appearance of this lesion 
in a patient who was under the writer's observation for three years. 
The aneurysm was discovered before it became visible. Dulness under 
the sternum with a bruit above the heart dulness was evident, and it pro- 
gressed to rupture. 

The rational signs of Aortic Aneurysm are : Pain, steady or in paroxysms, 
reflected to neck or arm, dry cough, dyspnoea, noisy respiration, hoarseness, 
aphonia, dysphagia, difference in pupil, dilatation of surface veins or oedema 




LYMPHATIC SYSTEM 



363 



of head and arm, an impressible fluctuating expansile tumor, dull on per- 
cussion with or without systolic thrill or murmur, or double murmur. 

Percussion is negative excepting in aneurysm near enough to the chest 
wall to give dulness. There is usually a difference in the radial pulse. 
In aneurysm of the descending portion of the arch, pressure is exerted 
against the dorsal vertebra?, causing erosion and great pain, and a tumor 
may appear posteriorly. 

In discriminating aneurysm from mediastinal tumor, pulsating empyema, 
aortic insufficiency, neurotic pulsation of aorta, displaced heart, a careful 
clinical history and examination will establish the diagnosis by exclusion. 
Aneurysm of the aorta may develop and expand posteriorly between the 
roots of the lungs and compress a bronchus to such an extent that the lung 
becomes atelectatic and dull on percussion and hides the thrill and murmur 
of the aneurysm. 

Aneurysm of the Abdominal Aorta 

The rational signs are pain, vomiting, epigastric pulsations, a tumor 
which pulsates occasionally, and a disturbed rhythm of the femoral pulse. 
A bruit may be present or absent. The aortic pulsation in hysterical women 
must not be mistaken for aneurysm. In a psoas or lumbar abscess there is 
no thrill and no bruit. 

The prognosis is not so serious as in aneurysm of the aortic arch. 

Aneurysm of the Splenic Artery. — This gives symptoms akin to those 
of gastric ulcer — pain and ha?matemesis. The diagnosis is very difficult 
unless it were possible to recognize a pulsating tumor in the left hypo- 
gastrium by physical signs or by means of the fluoroscopy 

Arteriovenous Aneurysm presents no special clinical phenomena. 

Treatment of Aneurysm. — The treatment of an accessible or external 
aneurysm is surgical, by ligature or excision or both. If pressure can be 
applied between the aneurysm and the heart it maybe tried before operating. 

The symptomatic management comprises digital pressure, a tourniquet, 
a bag of shot, rest in bed, cold to the sternum, iodide of potassium and 
arsenic internally, subcutaneous injections of gelatin (40 injections of 5j 
each), galvanopuncture, repeated venesection, and occasional morphine 
injections to quiet pain. 

LYMPHATIC SYSTEM 
LYMPH STASIS; LYMPH ANGEITIS ; ACUTE AND CHRONIC 

LYMPHADENITIS 

GENERAL REMARKS 

Lymph is a transudate of the blood through the capillaries. It gets to 
the parenchymal cells laden with nutrient material and eventually carries 
away certain products of combustion which it returns to the circulation. 

The composition and quantity of lymph must be different in different 
parts of the body and in accordance with the needs of the part. Difficulties 
in the transit of lymph through the capillaries, if they exist, are not recog- 
nized clinically. The clinical interest centres in the accumulation of lymph 



364 



THE CIRCULATORY SYSTEM 



in spaces and cavities. The pressure in the lymph system is dependent 
upon arterial pressure and is modified by the counterpressure offered by the 
various tissues. 

Lymph Stasis. — Lymph canals may become obliterated or dilated 
(lymphangeiectasis) or become inflamed (lymphangeitis). When the super- 
ficial lymphatics are blocked, the skin is covered with blebs or vesicles. 
We see this condition occasionally on the scrotum or vulva. Dilated 
lymphatics may present as distinct tumors (lymphangeiomas). The massive 

tongue of cretins (macroglos- 
sia) is an illustration of the 
hypertrophic condition of tis- 
sue from lymph stasis. 

A most remarkable case of 
lymph stasis has been under 
the writer's observation for 
many years. The young man, 
now twenty-four years old, and 
whose picture is here produced, 
was born with the deformity. 
His mother is in good health; 
the father died at the age of 
fifty-six, of diabetes. Five 
other children are normally 
developed. The young man 
is able to use his enormous right 
arm for all purposes, and is a 
fair performer on the banjo 

Fig. 120— Unique Case of Chronic Lymph and guitar. The arm is one 

Stasis. dense, hard tissue with several 

sacs of spongy tissue in the 
dependent parts. On scarifying this spongy skin, the lymph comes out 
in heavy drops, and a pint can be gathered in the space of an hour. The 
young man is afflicted with epileptic seizures, but complains very little 
about his arm. 

LYMPHANGEITIS AND LYMPHADENITIS 

Inflammation of the lymph vessels is associated with swelling or inflam- 
mation of the lymph nodes, and is due to infection. Lymph nodes hold 
up the infecting material and become swollen and inflamed themselves, 
such infection terminating in resolution or pus formation. Occasionally 
septic products appear to pass or escape the glands, and general sepsis or 
blood poisoning ensues. 

Symptoms. — Red lines run from the wound to the nearest lymphatic 
glands. The parts are painful and tender. The patient may have in addi- 
tion chills, fever, vomiting, and diarrhoea. 

Treatment. — Moist antiseptic dressing to the portal of infection, with 
elevation and rest of the affected part, a cold lead lotion or hot fomentations 
to the inflamed parts, and the free use of the knife to allow of the escape of 
pus or seropus, should it form. 




LYMPHANGEITIS AND LYMPHADENITIS 



365 



Acute Lymphadenitis is treated by applying cold (ice bag) or heat, by 
the hot water bag or a poultice. Incision or excision may become necessary. 
The glands in the neck, axilla, and groin are the principal glands to suffer 
infection. An acutely inflamed gland may be ready for the knife in a short 
time. On the other hand, there are cases of subacute intensity with 
circumglandular induration and swelling and semifluctuation which require 
surgical interference before abscess formation. If for any reason whatsoever 
it is not desirable to enucleate such glands, a free incision extending through 
the capsule of the gland may be made and the latter broken up by manipulat- 
ing with a blunt dressing forceps or by scraping with a sharp spoon, after' 
which the wound must be kept open under a moist bichloride or iodoform 
dressing. Such manipulations are painful and should be done under 
anaesthesia. A superficial and accessible glandular abscess may be cut 
open without anaesthesia, provided the patient will hold or can be held still. 

Chronic Lymphadenitis. — The following diagram will aid us in our con- 
ception of the term lymphoma: 



In chronic lymphadenitis we discriminate between the simple, tuber- 
culous, and syphilitic varieties. 

In simple hyperplastic lymphoma, an affection which is found mostly 
in children in the first decennium of their lives as the result of a chronic 
peripheral irritation, such as eczema, nasal or pharyngeal catarrh, hyper- 
trophied tonsils, carious teeth, etc., the glands are comparatively small, 
painless, and movable, and they show no tendency to break down and 
discharge their contents and form scars. 

The glands most frequently affected are the cervical, axillary, peri- 
bronchial and pericesophageal (mediastinal), mesenteric, and inguinal. 
Whenever we meet with enlarged lymph nodes we should endeavor to seek 
the cause or portal of entrance of the infecting and irritating agent. Occa- 
sionally the primary focus has cleared up, but the gland remains enlarged, 
and in some cases glandular enlargement accompanies anaemia and mal- 
nutrition without any appreciable local source of irritation. Cervical and 
mediastinal lymph nodes are readily infected from the buccal cavity, the 
nasopharynx, the bronchi and oesophagus; the mesenteric and inguinal 
glands are infected from the intestine and genitourinary tract. 

Tuberculous Lymphomata. — The glands vary in size from that of a pea 
to that of an egg. Tuberculous lymphomata are most frequent in the second 
and third decennia. Another point quite characteristic of tuberculous 
lymphomata is the presence of packages consisting of a number of glands 
of different size connected together. Tuberculous glands may be freely 



Lymphoma. 




fSimpIe Hyperplastic Lymphoma. 
.Chronic Lymphadenitis ' Tuberculous Lymph oma. 

ISyphilitic Lymphoma. 



366 



THE CIRCULATORY SYSTEM 



movable or more or less fixed. In one case the tuberculous process is 
entirely intraglandular and in the other case it has extended to or beyond 
the capsule, causing this latter to react by inflammation with the pro- 
duction of thickening of the capsule and its attachment to the surrounding 
parts. In the one case you have the tuberculous process without peri- 
adenitis, in the second case with periadenitis. The presence of scars shows 
that the tuberculous process has gone even one step further, viz., to the 
formation of abscesses. When a tuberculous abscess, after its formation 
within a lymph node, comes to the surface, it does so by perforating the 
thickened capsule through a small fistulous opening and by emptying 
itself into the subcutaneous connective tissue, lifting up the skin and forming 
a subcutaneous abscess. Afterward the skin breaks at some point, fistulse 
with fungous granulations result, which take a long time to close. From the 
complicated shape of the abscess cavity — partly intraglandular, partly 
subcutaneous — and the long duration of the discharge it can readily be 
understood why the tuberculous scars always have a characteristic irregular 
shape, never linear and smooth, usually drawn out in radiating lines, show- 
ing retractions here and prominences there, and becoming adherent to the 
underlying parts. 

Syphilitic lymphomata occur in all three stages of syphilis. In the first 
stage we find large, painful glands in the submaxillary or submental region, 
with a history of recent origin, and we find the initial lesion on the lips, 
tongue, tonsil, or other part of the mucous membrane. In the secondary 
stage we find small nodes, not larger than a bean, in almost all parts of the 
body where glands are found; they are painless, freely movable, and never 
break down. Gummata of the glands, found in the third stage of the 
disease, are rather rare. They grow slowly, are painless, have a firm, elastic 
consistency, and average about the size of a walnut. At first they are not 
adherent; later, as the gumma breaks down, it becomes adherent to the 
skin, breaks through and forms the characteristic syphilitic ulceration. 

As for malignant lymphomata, they are, in an early stage, often indis- 
tinguishable from tuberculous glands, appearing, as they usually do, at 
first on one side of the neck as numerous nodes of moderate size, about that 
of a bean, but without any peripheral lesion being found. Later on, how- 
ever, they increase steadily in size and number, some of them growing to 
the size of an apple, displacing and compressing the neighboring organs. 
They never break down, never invade the capsule, and never form adhesions 
with the surrounding parts. Death results from increasing weakness or 
from pressure upon important organs. 

Lymphosarcoma occurs as a single tumor always, which rapidly grows 
and invades the neighboring parts, becoming fixed. 

Of secondary malignant tumors it will suffice to say that they follow 
in the course of primary malignant tumors, are at first freely movable, and 
later become attached to the surrounding parts. 

Treatment. — Acute lymphadenitis without abscess and simple hyper- 
plastic lymphoma require treatment only of the original site of infection; 
syphilitic glands never require surgical treatment, except some cases of 
broken down gummata; malignant lymphomata turn out fatal, even 
where the most painstaking attempts at thorough removal are made; 



LYMPHANGEITIS 



AND LYMPHADENITIS 



367 



lymphosarcomata are capable of removal only in the earliest stage of their 
development. Secondary malignant tumors of course should be removed 
if possible, but that is usually done when the operation for the primary 
carcinoma is performed. Tuberculous lymphomata, however, very fre- 
quently require surgical treatment. By no means should all cases of tuber- 
culous lymphomata be operated upon. A great many patients may get 
well without operation, especially children, by placing them in the best 
possible surroundings, giving them good nourishing food and tonic treat- 
ment. We may even say that there is no stage of the disease in which a 
spontaneous cure is impossible. This favorable outcome is of course most 
likely to occur in the earliest stages of the disease, in those cases where the 
glands show only a hyperplasia, with perhaps a few tubercles scattered 
through their substance. But even cheesy foci may become encapsulated, 
abscesses may discharge until all the necrotic portions of the gland have 
been thrown out, and the process thus terminates in a cure. If, in spite 
of prolonged general treatment, the glands continue to increase in size, 
or if they break down and form abscesses or fistulse, the indication for 
surgical treatment is given. For cosmetic reasons a method of conservative 
surgical treatment has been devised to obviate making incisions by in- 
jecting certain substances into the tuberculous lymphomata or abscesses. 
For this purpose a 5 to 10 per cent emulsion of iodoform in glycerin or oil 
is commonly used. Chloride of zinc and other chemicals have also been 
employed. These methods are to be recommended only in cases where 
there is but a single tuberculous lymph node or abscess. The preferable 
treatment is either by incision and scraping out or extirpation, the former 
in cases of abscess with fistula, the latter for more or less solid glands. 
In the submental region the incision is usually made from the chin to the 
hyoid bone; in the submaxillary region, parallel with the horizontal ramus 
of the lower jaw; in the supraclavicular region, by an incision parallel to 
the clavicle; in the sternomastoid region, where the glands are found most 
frequently, by incisions in front of and behind the sternomastoid muscle. 
These incisions will usually give sufficient room, but if necessary the muscle 
should be divided transversely, in order to give more room, and be reunited 
at the end of the operation. The wound is then sewed up and a drain 
inserted at the bottom. In cases without periadenitis the operation is 
quite simple, the difficulty increasing in direct proportion to the amount of 
periadenitis and requiring in many cases very delicate dissection to free 
the glands from the important structures of the neck. 



CHAPTER XIII 



THE CIRCULATORY SYSTEM — Continued 

CONDITIONS OF THE BLOOD 

Synopsis: Terminology and Definition of Blood Conditions and Remarks on Leucocytosis. — 
Anaemia from Haemorrhage. — Chlorosis. — Pernicious Anaemia. — Secondary Anaemias. — 
Pseudoleucasmia. — Leucaemia. — Splenic Anaemia. — Purpura and the Hemorrhagic 
Diathesis. — Haemophilia. — Remarks on Haemorrhage. — Septicaemia and Pyaemia. 

GENERAL REMARKS 

Modern medicine is concerning itself more and more with haemato- 
pathology. From a clinical standpoint, the blood may be looked upon 
as a tissue liable to become infected and to carry infection to all other 
tissues, and any organ of the body may become diseased through the blood. 
On the other hand, pathological changes in one or more of the various 
organs produce pathological changes in the blood. When blood changes 
occur without demonstrable lesions of organs, we speak of blood disease or 
blood conditions. 

Terminology and Definition 

Normally, the red blood cells, or erythrocytes, vary very little in size. 
Abnormally, they are classed according to size : 

1. Microcytes are cells smaller than normal. 2. Megalocytes are cells 
larger than normal. According to shape, we have: 3. Poikilocytes, irregu- 
larly shaped. According to the presence of a nucleus: 4. Normoblasts, nor- 
mal sized nucleated red blood cells. 5. M egaloblasts , nucleated red blood 
cells larger than normal. 6. Gigantoblasts , nucleated red blood cells con- 
siderably larger than normal. 

When red blood corpuscles are destroyed in the blood, the iron in the 
liver increases. (This is not the case in acute haemorrhage.) In a change 
from the sea level to an altitude the red blood corpuscles increase in number, 
and vice versa. Under normal conditions, there are about 5,000,000 red 
blood cells to the cubic millimetre of blood. The bulk of the red blood 
cell is composed of haemoglobin, an albuminous body, rich in an iron pig- 
ment. This body is of extreme importance, as it carries oxygen from the 
lungs to the tissues where it is required. 

When haemoglobin leaves the red blood corpuscles and enters the blood 
plasma, its energy as an oxidizer ceases. In this instance it is transformed 
into bile pigment in the liver or under pathological conditions it may leave 
the body with the urine (haemoglobinuria). The dissociation of haemoglobin 
from the corpuscle is observed in systemic poisoning and in transfusion 
368 



TERMINOLOGY AND DEFINITION 



369 



of blood from one animal species to another. When the haemoglobin in 
the general circulation is diminished, the individual shows a peculiar pallor, 
and we then speak of ancemia. Some individuals have naturally a pale 
complexion without being ana?mic. 

The Leucocytes. — In classifying the white blood cells, the terms neutro- 
phile, basophile, and acidophile are used to indicate the chemical selective 
properties of the cell granules and nuclei. 

Leucocytes are classed as follows: 

Normal blood contains: 

1. Lymphocytes are slightly larger or smaller than red blood cells. They 
contain a single nucleus which stains very deeply and occupies the greater 
part of the cell. 

2. Large uninuclear leucocytes may be only slightly larger than the 
lymphocytes, but many of them are the largest cells seen in the normal 
blood. The nucleus is vesicular, rather than reticulated, as it is in the 
lymphocytes, and does not stain quite so deeply. 

3. Multinuclear leucocytes, the most numerous variety, are two or three 
times as large as a red blood cell. The nuclei are elongated, constricted, 
or composed of two or more lobes, usually connected by a thread of chro- 
matin or completely separated from one another. 

4. Eosinophile leucocytes vary in size from that of a lymphocyte to that of 
a multinuclear leucocyte and contain in the cell protoplasm strongly acid- 
ophile granules. Their nuclei resemble those of the multinuclear leucocytes. 

The Pathological Leucocytes. — I. Myelocytes are uninuclear cells 
the protoplasm of which has neutrophile or eosinophile granules. 

1. Ehrlich's myelocytes are medium-sized cells with pale, usually central, 
nuclei and neutrophile granules. 

2. Cornil's myelocytes are large cells, much larger than a multinuclear 
leucocyte, with a pale eccentric nucleus and neutrophile granules. 

3. Eosinophile myelocytes may resemble the eosinophile cells of normal 
blood, except that their nuclei are single. 

II. Mast cells are uninuclear or multinuclear cells of different sizes, 
the characteristic feature of which is the presence of large and small baso- 
phile granules. 

General Conditions. — Blood plates have been much discussed, but little is 
known about them. They are very small, round or ovoid, colorless, homo- 
geneous or granular bodies of about \ or J the size of a red blood cell, usually 
showing no nuclear portion and staining faintly by both acid and basic 
dyes. They are found in both normal and pathological blood. Well nour- 
ished individuals have about 8,000 white cells in a cubic millimetre of 
blood; children have about 9,000. 

The blood plasma contains from . 1 per cent to . 4 per cent of fibrin. 
An increase of fibrin, hyperinosis, 1.0 to 1.3 per cent, is found in pneu- 
monia, pleurisy, and articular rheumatism. A decrease of fibrin, hypinosis, 
is found in typhoid fever, sepsis, and pyogenic diseases. 

The serum is the plasma without the fibrin. The recent work with 
antitoxines shows that its study in health and disease has a great future. 

Plethora is a term used to indicate an abnormal fulness of the blood 
vessels due to an increase of the quantity of blood in the body. The amount 



370 



THE CIRCULATORY SYSTEM 



of blood in the blood vessels is normally influenced by many conditions, 
such as the constitution and muscular development, sex, period of life, 
digestion, etc. 

Plethora serosa, or hydroemia, is a diminution of the albumin contained 
in the plasma. It has been demonstrated in many of the infectious dis- 
eases. It is also found in inanition, anosmia, malignant tumors, and cardiac 
insufficiency. 

Lithcemia is a term used to indicate that condition, gouty or otherwise, 
in which there is an increase of uric acid or urates in the blood. 

Urcemia indicates the phenomena caused by the retention of certain 
excrementitious substances in the blood which are normally eliminated 
by the kidneys. The nature of these poisonous substances is not fully 
understood, but it is supposed that they are autotoxic. 

Lipoemia, or the presence of free fat in the blood, is found both in health 
and in disease. Its real pathological significance is doubtful. 

Lipacidcemia. — Fatty acids have been found in the blood by von Jaksch 
in diabetic coma, leucaemia, acute yellow atrophy of the liver, and in the acute 
infectious diseases. 

Acetonemia. — Acetone has been isolated from the blood in many patho- 
logical processes, particularly in fevers. 

Cholaemia is a name given to those grave symptoms of poisoning which 
are due to the presence of bile and bile acids in the blood. 

Hoemoglobinoemia is applied to the condition in which haemoglobin is in 
solution in the blood, due to a lessened resistance on the part of the red 
blood cells. It is found after extensive burns, acute poisonings, infectious or 
otherwise, and after transfusion of blood from one animal species to another. 

Pyaemia is the name given to that condition in which pyogenic bacteria 
are present in the blood and there is a tendency to the formation of pus 
foci and abscesses in different parts of the body. 

Septicaemia also indicates the presence of bacteria and their poisons in 
the blood without a tendency to abscess formation in different parts of 
the body. 

Toxaemia is used to designate the presence of some poisonous principle 
in the blood. 

Oligocythasmia is a condition of the blood usual soon after a hemorrhage, 
in which there are fewer red blood cells than normal. 

Polycythemia, an increase in the number of red blood cells, is usually 
due to a decrease in the amount of the plasma. It is found in diarrhoea, 
dysentery, cholera, or any disease attended with excessive watery exudates 
and in conditions, such as endocarditis, emphysema, and asphyxia, in which 
there is insufficient aeration of the blood. It is also observed in people at 
great altitudes. Various drugs, such as phosphorus, pilocarpine, eserine, 
etc., and cold baths may cause it. 

Polychromasia is a word used to indicate the property of the red cells 
in various forms of anaemia and in the normal bone marrow when they 
acquire a diffuse brownish stain. 

Haemophilia is the name applied to that hereditary or acquired constitu- 
tional anomaly which predisposes the subject to persistent and often fatal 
haemorrhage of traumatic or spontaneous origin. 



LEUKOCYTOSIS 



371 



LEUCOCYTOSIS 

Leucocytosis is a term used to indicate a temporary distinct increase 
of the number of leucocytes above the normal. 
Rieder's Classification: 

(a) Physiological leucocytosis. 

1. Leucocytosis of digestion. 

2. Leucocytosis of pregnancy. 

3. Leucocytosis of the new-born. 

(b) Pathological leucocytosis (which seems to be an effort of Nature to 
overcome infection). 

1. Post hemorrhagic leucocytosis. 

2. Cachectic. 

3. Ante-mortem (agonal, terminal, leucocytosis of the moribund). 

4. Leucocytosis of acute injections. 

In inflammatory conditions, leucocytosis is said to indicate a good prog- 
nosis. 

Physiological Leucocytosis. — Digestion. — After eating it has been ob- 
served that in healthy individuals the leucocytes may increase up to 15,000 
to 16,000. In a number of gastric disorders in which torpidity of the stom- 
ach and bowels exists, they fail to increase. The increase is not a reliable 
diagnostic test of gastrointestinal disorders, because it is frequently present 
in other conditions. 

Pregnancy. — During the latter months of pregnancy there is usually a 
leucocytosis, which may be as high as 20,000. 

In the new-born there may be as many as 20,000 leucocytes. Normally 
the number gradually diminishes until the child reaches the age of eight or 
ten years, at which time the number is the same as in adults. 

Pathological Leucocytosis. — It is usual to find a leucocytosis following 
hemorrhage. In general it is in proportion to the extent and rapidity of 
the loss of blood. It usually disappears or is greatly diminished long 
before the red cells are restored to their normal numbers (Ewing). 

Cachectic leucocytosis is observed in chronic anemia, local inflammations, 
and chronic toxemia. In tertiary syphilis, tuberculosis, nephritis, carcinosis, 
and rather a smaller proportion of sarcomata cachexia is unaccompanied 
by leucocytosis unless there is a distinct local inflammation, necrosis, or 
hemorrhage. 

Ante-mortem, or agonal, leucocytosis has been found in a great many 
diseases, but it has not been sufficiently studied to make the examination 
of the blood of any particular value. 

Leucocytosis of Acute Infections. — It is in this connection that the study 
of the number of the leucocytes is of value in diagnosis, prognosis, and treat- 
ment, although much more work needs to be done. Such a leucocytosis 
is found in pneumonia, diphtheria, scarlatina, and all purulent exudative 
inflammations. It is absent in the following diseases when they are un- 
accompanied by local inflammatory conditions: Typhoid fever, measles, 
tuberculous conditions, and acute malarial seizures. 

In pneumonia there is an initial hypoleucocytosis succeeded by a marked 
hyperleucocytosis which continues throughout the disease and is unaffected 



372 



THE CIRCULATORY SYSTEM 



by pseudocrises. The more severe and extensive the pneumonia the 
greater the leucocytosis. Sometimes the initial hypoleucocytosis remains, 
indicating a very bad prognosis. Counting of the leucocytes may be of 
great value in distinguishing between pneumonia and typhoid fever or 
malarial disease. 

In diphtheria, the counts are about the same as in pneumonia, but are 
of no value in prognosis. 

In typhoid fever, there is no leucocytosis unless inflammatory complica- 
tions exist. It is usual to have a lymphocytosis. Counting of the leucocytes 
thus aids in the distinction between appendicitis and typhoid fever. 

In tuberculous conditions, a leucocytosis may indicate a secondary 
infection, such as an empyema, a cavity with suppurating walls, or a haemor- 
rhage or cachexia. 

Generally speaking we may say that a single observation as regards leu- 
cocytosis is of little value. Even where we make successive observations, 
and there has been progressive increase in the number of leucocytes, if the 
percentage of polynuclears does not go up, it really means nothing. 

Eosinophilia. — The increase in the number of eosinophiles found in 
various pathological conditions has not as yet offered much definite aid 
in diagnosis and prognosis. Of late, several investigators have observed 
a remarkable increase of these cells, even to 68 per cent, in the acute stage 
of trichiniasis. The increase seems so constant in this disease as to make 
it advisable to count the eosinophiles in all febrile conditions of doubtful 
origin, and especially in those cases in which indefinite.intestinal and mus- 
cular symptoms exist. 

Lymphocytosis. — Lymphocytosis is often of considerable importance. It 
has been found to exist in the so called lymphatic constitution, in idiopathic 
epilepsy, in Basedow's disease, in rhachitis, in typhoid fever, in diphtheria, 
in bronchopneumonia, in pertussis, during measles, at the close of scarlet 
fever and smallpox, during prolonged lysis in pneumonia, in the less acute 
diarrhoeas of infancy, in chronic diseases involving lymphatic tissues, etc. 

ANAEMIA 

Simple Anaemia from Hemorrhage 

If the patient survives the loss of blood, from whatever part of the 
body it may occur, regeneration goes on with great rapidity. The watery 
and saline elements are absorbed rapidly from the digestive tract and the 
albuminous elements are quickly renewed. The corpuscles are increased 
in number more slowly, weeks or months being required for them to reach 
the normal number. The haemoglobin is the last to reestablish its normal 
percentage. 

The symptoms are those of anaemia, secondary to other causes described 
under Secondary Anaemia. Great dyspnoea, "air hunger," one of the most 
distressing sights the physician can witness, may follow severe haemorrhage. 

The treatment is to supply fluids by drinking or by giving saline enemata 
or intravenous injections of normal salt solutions. In addition to this, food 
and proper hygiene are essential. 



ANAEMIA 



373 



Chlorosis 

Chlorosis (green sickness) is a special form of primary anaemia mostly- 
seen in young women at or a little beyond puberty. It is almost always 
associated with incomplete development of the vascular and generative 
systems. Chlorosis has been attributed to autoinfection from the gastro- 
intestinal tract and also from the ovaries. 

Pathology. — The essential characteristic of the blood in chlorosis is reduc- 
tion of the haemoglobin. In ordinary cases the amount averages 40 per cent, and 
in severe cases may be as low as 20 per cent. The number of red cells is usually 
reduced, although exceptionally it is normal. They are never reduced in pro- 
portion to the haemoglobin. They are pale in color, and poikilocytes, microcytes, 
and normoblasts are seen. The leucocytes are slightly increased in number. 

etiology. — This disease seems to be in some way associated with the 
evolution of the sexual life in young women, but we know very little as to 
its real cause. Heredity seems to play a part in some cases. A chlorotic 
history on the maternal side or a tuberculous family history has been noted 
in certain instances. Although it is most frequent among the poor and 
overworked factory girls who live amid unhygienic surroundings upon insuffi- 
cient or improper food, it is not uncommon among young women of the 
higher classes. A blood poisoning from the absorption of toxic principles 
elaborated in the constipated bowel has been mentioned as a cause, and 
Virchow suggests a lack of development of the arterial system. 

Symptoms. — The symptoms are those of secondary anaemia, especially 
the nervous and dyspeptic symptoms. The color of the skin, instead of 
being simply pale, as in anaemia, is greenish yellow, which is characteristic, 
giving the disease its name of " green sickness. " The gastrointestinal symp- 
toms, nausea, vomiting, epigastric pain, and constipation are prominent. 
Occasionally vomiting of blood renders the distinction from gastric ulcer 
very difficult, as ulcer of the stomach may exist in chlorotic women. 

A decrease of the gastric juice with hyperacidity is frequent. The 
appetite is capricious and often perverted, acid foods being longed for. 
Gastroptosis is sometimes found in chlorotic girls. Emaciation is very 
unusual. (Edema of the ankles and puffiness of the face, arousing the 
suspicion of nephritis, may be noticed. Irregular fever sometimes exists. 
Dyspno?a, amenorrhea, mental depression, irregular nervous symptoms, 
languor, and lassitude are usual. 

Diagnosis. — The diagnosis is usually based upon the age, the sex, the 
amount of haemoglobin, and the rapid improvement from the use of iron 
combined with mild laxatives. 

It is distinguished from nephritis by analysis of the urine and from 
severe anaemia by a blood examination. 

Prognosis. — The prognosis is favorable, provided sufficient iron is 
administered and the patient is able to assimilate it. Relapses, however, 
are frequent and prolong the course of the disease. 

Treatment. — Iron is a specific, and if it is given and is properly assimi- 
lated, the amount of haemoglobin increases from 5 to 10 per cent each week. 
It is best to continue its use until the haemoglobin is above 90 per cent. 
The carbonate of iron, or Blaud's pills, seem to be the best preparations. 



374 



THE CIRCULATORY SYSTEM 



The tartrate of iron and potassium, the pyrophosphate of iron, and liquor 
peptomangan are also good forms of iron in this disease. 

Fresh air, improved hygiene, sufficient, good, nourishing food, and the 
prevention of constipation are important adjuvants to the medical treatment. 
Moderate exercise is indicated, and inhalations of ozone are also beneficial 
in the management of chlorosis and other forms of anaemia. 

The Balloon Treatment op Anaemia. — Dr. Naugier, of Paris, has 
found that a balloon voyage in the upper air strata for an hour or two results 
in a very notable increase in the number of red blood corpuscles, which in- 
crease persists for a quite considerable time. There is, so far as we can see, 
nothing antecedently improbable in this assertion, and it seems likely that 
balloon ascents may, in the not distant future, prove of the utmost service 
in cases of severe anaemia. Should this prove to be the case, the provision of 
"hospital balloons," as suggested by Dr. Naugier, may prove an efficient 
and little expensive means of providing a literal " change of air " for those 
unfortunate denizens of cities who are unable to compass such a desirable 
result in any of the more usual ways. 

Progressive Pernicious Ancemia 

Essential anaemia and idiopathic anosmia are synonyms. It is a progres- 
sive disease of unknown origin, with lesions found in the blood, liver, and 
bone marrow. 

Occurrence. — The disease is widely distributed, and usually occurs in 
adult life. Children are rarely affected. The progressive anaemia associated 
with pregnancy, atrophy of the stomach, and certain intestinal parasites, 
especially the Bothriocephalus lotus and the Ankylostomum duodenale, are not 
included under this disease. 

Pathology. — The blood is pale and diminished in quantity. The red 
blood cells may be diminished to 1,000,000 or even to 500,000 or 200,000 
in a cubic millimetre. The haemoglobin is proportionally reduced, reaching 
30 per cent and lower. A characteristic feature of pernicious anaemia is 
that the remaining red blood cells contain the normal or even a larger 
amount of haemoglobin than normal. Microcytes, megalocytes, normoblasts, 
megaloblasts , and poikilocytes are found. The leucocytes are normal in 
number, or they may be reduced. 

The liver may be enlarged and fatty. Iron is present in this organ to 
an abnormal amount, a condition possibly peculiar to pernicious anaemia 
(Hunter). The spleen and kidneys also show an increase in the amount of 
iron. The bone marrow is lymphoid in character and contains a large number 
of nucleated red blood cells, particularly gigantoblasts , and it resembles the 
bone marrow of a child. 

Symptoms. — The disease advances slowly and insidiously. The patient 
cannot fix a time when he first noticed that he was not well. A feeling 
of 1 anguor, soon becoming extreme, associated with a peculiar waxy white 
or pale lemon pallor, a flabby, fat frame, faintness, and dyspnoea are the 
principal symptoms. The debility gradually becomes very marked, synco- 
pal attacks become frequent, and capillary pulsation, visible pulsations 
of the arteries, and haemic murmurs are detected. The superficial veins 



ANEMIA SECONDARY TO OTHER DISEASES 375 



may pulsate. The ankles become slightly cedematous. The urine is 
usually low in specific gravity, is of high color, and contains an excess of 
urobilin. It may, however, be pale. The gastrointestinal symptoms of 
anaemia are present. Diarrhoea is not infrequent. An irregular slight rise 
of temperature is usual, 100° to 101° F., but it may be subnormal or as high 
as 103° or 104°. The tendency to haemorrhages is seen in purpuric spots in 
the skin and mucous membranes. Retinal haemorrhages are common. 
The languor, faintness, and dyspnoea increase, the patient falls into a half 
torpid delirium, and at length expires after an illness of several months. 

Prognosis. — The prognosis is usually bad, although patients recover 
after the use of the arsenical treatment. If the red cells fall below 1,000,000, 
and there is a relatively large number of megaloblasts, particularly giganto- 
blasts, the prognosis is unfavorable. Fatal cachexias with or without 
anatomical lesions and associated with gastric anacidity have been re- 
ported. 

Diagnosis. — According to Ewing, the diagnosis may rest upon the 
presence of numerous ?negaloblasts and megalocytes with relatively increased 
haemoglobin, 33 per cent of megalocytes with relatively increased haemoglobin, 
or an excess of megaloblasts over normoblasts — a single gigantoblast or megalo- 
blast in pathological mitosis. The diagnosis cannot be based upon an extreme 
reduction of red cells. The diagnosis may require the complete summation 
of all the clinical and morphological data, as well as observations on the 
course of the disease, or even microscopical examination of the marrow. 
In making the diagnosis of pernicious anaemia the condition of the blood 
is not in itself conclusive. 

Treatment. — As iron has never been shown to be of benefit in these 
cases, it is unnecessary to try it. Arsenic in increasing doses has cured a 
few cases and improved many. It is advisable to administer three minims 
of Fowler's solution three times a day to begin with, increasing to five 
minims at the end of the first week, ten at the end of the second, fifteen 
at the end of the third, and, if necessary, up to twenty or thirty, watching 
for vomiting and diarrhoea, which are the first symptoms of an overdose. 
Rest in bed, a light, nutritious diet, and oral and intestinal antiseptics 
are adjuvants, and dilute hydrochloric acid should be given after each meal 
to aid digestion. 

Ancemia Secondary to Other Diseases 

This form is due to long continued drain on the albuminous material 
of the blood. This is found in Bright's disease, chronic suppuration, pro- 
longed lactation, and rapidly growing malignant tumors, such as cancer; or 
to inanition and defective nutrition, insufficient or improper food, digestive 
disturbances, improper modes of life, or intestinal parasites. 

Toxic Anaemia. — The use of certain drugs to a degree of poisoning, 
such as lead, mercury, arsenic, and salicylic acid, causes anaemia. Syphilis, 
malaria, and the infectious diseases, tuberculosis, and pyrexia, which cause 
an elaboration of organic poisons, also cause a secondary anaemia. 

Pathology of Secondary Anaemia. — The number of corpuscles, the per- 
centage of haemoglobin, and the fluid constituents of the blood are all 
diminished. The red cells usually show a more marked difference in size 
25 



376 



THE CIRCULATORY SYSTEM 



than normally, and they may be smaller than normal (microcytes) . A 
moderate poikilocytosis may be present. Nucleated red blood cells (normo- 
blasts) are always found. They are more abundant in the secondary antenna 
caused by a long continued drain upon the albuminous constituents of the 
blood than from the other causes. 

Symptoms. — 1. Pallor. — Pallor of the skin and mucous membranes. 
The colorless appearance of the conjunctivae roughly indicates the anaemic 
condition, but as not all pale people are anaemic, and vice versa, more 
reliance should be placed upon counting the red cells and upon estimating 
the amount of haemoglobin than upon the appearance. 

2. Heart Symptoms. — The pulse is rapid and usually of low tension, 
although it occasionally may be of high tension. Syncope and palpitation 
are common. The heart may be slightly dilated. A systolic murmur which 
is not infrequently transmitted upward may be heard over the pulmonary 
area. It is not constant and is often more audible when the patient is 
lying down. A systolic murmur transmitted into the axilla may be heard 
at the apex, due to a relative insufficiency of the mitral valve arising from 
poor muscular tone or from slight dilatation of the left ventricle. There 
is a tendency to thrombosis , particularly in the femoral veins. 

3. Dyspeptic Symptoms. — These are usually present. The appetite 
is irregular and capricious, the tongue is coated, and the bowels are con- 
stipated. 

4. Lung Symptoms. — The dyspnoea upon exertion is in proportion to 
the degree of the anaemia. A slight cough without expectoration is frequent. 

5. Cerebral Symptoms. — There are often spots before the eyes, tinnitus 
aurium, and vertigo. Headaches, with the pain oftenest in the top of the 
head, are common. Mental apathy and inability to concentrate the mind 
are regularly present. 

6. Nervous and Hysterical Symptoms. — These are almost always 
marked. There are irritability and restlessness, sleeplessness, drowsiness 
by day, hot and cold flashes, peculiar sensations, and irregular pains. Languor 
and lassitude are constant. 

7. General Symptoms. — The temperature may be irregular and lowered 
in severe cases. A little a:dema of the legs and ankles is often seen. Emacia- 
tion is uncommon. If it is present, we suspect tuberculosis or carcinosis. 
Lack of endurance and bodily weakness are prominent symptoms. In 
women menstrual irregularities are frequent. Amenorrhea is common and 
should cause no anxiety. The menses may be scanty and light colored. 
Menorrhagia is sometimes seen. 

Diagnosis. — In addition to the above mentioned symptoms the diagnosis 
is made by examining the blood, the features of which are discussed under 
the heading of the pathology of this disease. 

Treatment. — By finding the cause, with accessory factors, such as 
improper modes of life, digestive errors, constipation, and intoxications, 
and removing them; by recognizing the value of fresh air, sunlight, and 
exercise without undue fatigue, we make it possible for the specific drug, 
iron, to act more quickly, thoroughly, and permanently. The usual pre- 
cautions in giving iron, to avoid headaches and constipation, should be 
observed by choosing the best forms in which to administer it. 



LEUCAEMIA (LEUCOCYTHjEMIA) 



377 



In those forms in which there is a continuous drain on the albuminous 
materials of the blood, it is very difficult to treat the malady so long as the 
cause of the anosmia remains. 

LEUC/EMIA (LEUCOCYTH>EMIA) 

This is a disease of the blood characterized by a continuous increase 
in the number of leucocytes, which are altered in character, associated 
with marked diminution of the red blood corpuscles, and changes in the 
bone marrow, spleen, and lymphatic glands, separately or together. 

^Etiology. — Although a great amount of most careful research has been 
undertaken in the study of this disease, the cause is still obscure. It may 
occur at any age, although it is most common in middle life. Males are 
more often affected than females. Heredity seems to have some influence 
upon its aetiology, and trauma, intestinal intoxication, bad hygiene, syphilis, 
malaria, rhachitis, latent tuberculosis, the constitutio lymphatiea, stomatitis, 
etc., have been cited as causes. A microbic origin has been suggested, 
because of the rapidly fatal course of some acute cases, which resembles 
the course of known infections. 

Ordinarily there are seen two main types, although combinations and 
variations may occur: Splenomedullary leucaemia, or the lienomyelogenous, 
and lymphatic leucaemia. 

Pathology. — 1. Splenomedullary Leuccemia. — The spleen is greatly en- 
larged, being in a condition of chronic hyperplasia. Grayish white circum- 
scribed tumors may occur throughout the parenchyma. There is also an 
extraordinary hyperplasia of the red marrow. The blood presents the 
most characteristic change and will be described under Symptoms. 

2. Lymphatic Leucaemia. — This is characterized by a general lymphatic 
enlargement, usually associated with some splenic and bone marrow hyper- 
plasia. The cervical, axillary, inguinal, and mesenteric glands are enlarged, 
but they remain movable, soft, and isolated. The tonsils may be enlarged. 
Peyer's patches and the solitary follicles may be enlarged. The bone marrow 
may be replaced by lymphoid tissue. The liver is occasionally enlarged, 
and the kidneys may be enlarged and pale. Increase in size of the thymus, 
thyreoid, arid suprarenal glands and the ovaries is sometimes seen. Leucaemic 
tumors in the various organs, probably developing from foci of leucocytes 
which have left the capillaries, are rather rare. 

Symptoms in General of Both Forms. — The beginning of the disease 
is insidious, and probably it has existed for some time before any real 
symptoms attract attention. Usually a progressive enlargement of the 
abdomen is first noticed, or there may be palpitation, shortness of breath, 
and other general anaemic symptoms. Indigestion, bleeding from the nose, 
or severe and even fatal haemorrhage from the stomach may be the first 
symptom. 

Splenomedullary Leucaemia. — This form is most often seen, and it is 
usually characterized by a gradual enlargement of the spleen, which may 
cause pain and be tender upon palpation. This organ may reach an enor- 
mous size, extending to the right and downward into the bony pelvis. Oc- 
casionally the margin is notched, and from time to time fremitus may be felt 



378 



THE CIRCULATORY SYSTEM 



over the spleen, resembling that between two layers of roughened pleura. 
The enlarged spleen may cause pressure symptoms. 

Cardiac Symptoms. — The apex beat may be displaced by the heart's 
being pushed upward by the enlarged spleen. Haemorrhages may occur 
into the skin, the pleura, or the peritoneal cavity. Haemorrhages from the 
nose are common, but haemoptysis and hematuria are rare. Haematemesis 
and bleeding from the gums, cerebral haemorrhages with coma, and bleeding 
into the retina, giving rise to retinitis, may be present. A retinitis due to 
leucaemic new growths has been noticed. Later in the disease oedema of 
the feet or general anasarca may develop, and at the end ozdema of the lungs. 
In the respiratory system shortness of breath is a most marked symptom. 

Gastrointestinal symptoms are very common. They are nausea, vomiting, 
diarrhoea, dysentery, haemorrhage from the intestines, and, occasionally, 
peritonitis and ascites, probably due to leucsemic new growths. 

The nervous system is not so much affected as in the anaemias. Vertigo, 
headache, and attacks of syncope are sometimes present. 

The ear is sometimes affected by haemorrhages, causing deafness or dis- 
turbances in equilibrium. Leucaemic new growths may occur in the tonsils 
or liver. In males priapism may be a very disagreeable symptom. A 
rise in temperature (102° to 103°) is common. The urine does not show 
very much. There may be albumin, and the amount of uric acid is usually 
increased. 

The blood alone offers the distinctive features upon which the diagnosis 
can be made. In the anaemias the red cells show the blood changes. In 
leucaemia it is the white cells that we observe for diagnosis. The leucocytes 
are enormously increased in number, often reaching 100,000 and not rarely 
500,000 a cubic millimetre. One form of leucocyte not found in normal 
blood, called, after Ehrlich, the myelocyte, may constitute 30 per cent of 
the white blood cells. These are large, uninuclear, neutrophilic cells which 
may vary much in size and may have notched nuclei undergoing mitotic or 
degenerative changes. Mast cells are present. The lymphocytes are not 
increased, but may be relatively diminished, as are also the multinuclear 
leucocytes. These also may be undergoing degenerative changes. The 
eosinophiles are increased in proportion, so that there is relatively a great 
increase. There are also seen, and held by Ewing to be pathognomonic 
in this disease, eosinophile myelocytes. 

There is a reduction in the hccmoglobin, which is often below 50 per cent, 
and the red blood cells are much reduced in number. Normoblasts are 
present in considerable numbers, and megaloblasts may be found. Mitotic 
changes in the nuclei of normoblasts have been observed. 

Lymphatic Leuccemia 

This is a rarer form, more rapid and fatal, and more common in young 
people. The blood changes are quite different from those of the spleno- 
medullary form. There is not such a great increase in the number of the 
white blood cells, and the increase is found to take place solely among the 
lymphocytes. Eosinophiles and normoblasts are rare, while myelocytes are 
absent. 



DIAGNOSIS OF LEUCAEMIA, TREATMENT, ETC. 



379 



Diagnosis of Leuccemia, Treatment, Etc. 

Diagnosis of Leucaemia. — This disease can be diagnosticated only by 
examining the blood. We must find among the leucocytes so increased 
in number: 1. Uninuclear granular lymphocytes (myelocytes). 2. Neutro- 
phil cells, eosinophiles, and mast cells (all much increased in number). 
3. Often dwarfed leucocytes and leucocytes whose nuclei are undergoing 
mitotic changes. These are, 
however, not diagnostic of 
leucaemia. 4. Always nucle- 
ated red blood cells, often in 
large numbers. 

The relative proportion of 
these cells varies greatly in 
the different cases. Some- 
times the eosinophiles are 
greatly in excess, sometimes 
the mast cells, and sometimes 
the nucleated red blood cells. 
An intercurrent disease great- 
ly changes the appearance of 
the blood. There is a marked 
diminution in the number of 
the white blood cells, and they 
rise again with improvement 
of the intercurrent malady. 

Mixed forms of leuccemia 
are not common, although 
different writers describe in- 
dividual cases. 

Acute leucaemia is the name 

given to the disease when it Fig. 121. — Splenomedullary Leucaemia. 

runs a rapid course. Some- Outline of the spleen before and after treatment with 

times the whole duration of * rays. (Dr. N. Senn.) 

the disease is less than two 

months. Such cases are usually of the lymphatic type, in young people, 
and large lymphocytes are frequently present in great numbers. 

Prognosis. — Although the course of the disease is progressive, appro- 
priate treatment may produce periods of temporary improvement. Acute 
cases may terminate in less than two months. The majority of cases prove 
fatal in from two to three years. Unfavorable signs are persistent diarrhoea, 
a tendency to haemorrhage, high fever, and early dropsy. 

Treatment. — The remedies given in this disease are usually those em- 
ployed in pernicious anaemia. Arsenic, in increasing doses, seems to be 
the best drug. Iron and the inhalation of oxygen seem to be of value in 
some cases. Quinine is given in malarial cases, and potassium iodide and 
mercury in luetic cases. Organotherapy may be tried. Operative pro- 
cedures are hardly advisable, owing to the tendency to haemorrhage. Re- 




380 



THE CIRCULATORY SYSTEM 



covery from splenomedullary leucaemia following x ray treatment has been 
reported by Dr. N Senn, of Chicago (Med. Record; Aug. 22, 1903). 

Pseudoleucosmia 

Synonyms: Hodgkin's disease, lymphatic ancemia, adenia, general lymph- 
adenia, pseudoleucocythamia, malignant lymphosarcoma. ' 

This disease is characterized by a general hyperplasia of one or more 
groups of lymphatic glands and by the presence of anaemia, and is frequently 
accompanied by lymphoid growths in the spleen, liver, and other organs. 

^Etiology. — The origin of this disease is also obscure. The latest theories 
as to its causation are that it is of infectious origin, and that it is caused 
by a local irritation from which the glands in the immediate neighborhood 
are first involved. It occurs in the majority of cases in young persons, and 
three fourths of them are males. Heredity has been supposed to have some 
aetiological bearing. Syphilis, malaria, and other antecedent diseases have 
also been asserted to be setiological factors. 

Pathology. — The lymphatic glands in all parts of the body undergo an 
unequal hyperplasia, usually in the following order: the cervical, axillary, 
inguinal, mediastinal, retroperitoneal, and mesenteric groups. 

The growth is gradual, the enlarged glands being at first soft and movable, 
then becoming hard and immovable and forming large masses which may 
invade the surrounding tissues, producing pressure symptoms. The glands 
nearest the skin sometimes undergo suppuration, and areas of necrosis 
may develop. On section, the mass is grayish white in appearance, at 
times firm and dry, at times soft and juicy. Microscopically, it is seen 
that the growth is chiefly confined to the cells, the reticulum sometimes 
becoming thickened and sometimes not. 

Secondary growths of lymphatic tissue may be developed in different 
parts of the body, at the base of the tongue and in the spleen, liver, kidneys, 
lungs, pleura, and spinal cord. The spleen is enlarged in about three fourths 
of the cases, and in about one half of them there are grayish white tumors 
in its substance. It is never so large as the spleen of leucaemia. The 
liver and kidneys are often enlarged. 

The changes in the blood are not marked, and they resemble those of 
ordinary anaemia. The red cells are diminished but seldom reach 2,000,000. 
The leucocytes are usually not increased in number. The lymphocytes may 
be more abundant than normally. Nucleated red cells may be present, but 
they are not so numerous as in leucaemia. 

Symptoms. — The first symptom noticed is usually the enlarged glands 
in the neck, axilla, or groin, although the anaemic symptoms are occasionally 
the first to appear — pallor, dyspnoea, haemorrhages, oedema, and cardiac and 
cerebral symptoms. As the glands become larger, pressure symptoms become 
manifest. The enlarged axillary glands, by pressing upon the brachial 
plexus, may cause swelling of the arm, and numbness, tingling, or pain along 
the course of the nerves affected. 

The trachea may be obstructed from cervical enlargements, sometimes 
necessitating tracheotomy. Bronchial lymphatic enlargements may cause 
pressure upon the trachea, oesophagus, bronchi, vena cava, or aorta. There 



PSEUDOLEUKEMIA AND SPLENIC ANEMIA 



381 



may be disturbances of the heart, lungs, or stomach as a result of pressure 
upon the vagi. Abdominal pain, ascites, portal obstruction, or jaundice 
may be caused by pressure of the enlarged retroperitoneal or mesenteric 
glands. Pressure upon the adrenals or upon the splanchnic nerves may 
cause bronzing of the skin. In involvement of the pelvic and iliac region 
sciatica and swelling of the leg are pressure symptoms. Dyspnoea may 
be due to the anaemia, to pressure upon the trachea, or to pleuritic effu- 
sion dependent upon mediastinal growths. Fever is present in most cases, 
and even in the early stages there is a slight rise of temperature. It 
may be of an irregular, hectic type, or continuous with evening exacerba- 
tions. Some patients have aguelike spasms which may persist for weeks 
or months. 

Diagnosis. — Tuberculous adenitis is distinguished by being more common 
in the young, by our not finding tuberculous signs elsewhere in the body, 
and by the fact that tuberculosis usually first attacks the submaxillary 
glands, while pseudoleucaemia usually first involves the glands along the 
borders of the sternomastoid muscle. Tuberculous glands may remain in 
one region for years, become moulded together and commonly suppurate, 
while suppuration of the glands is rare in pseudoleucaemia, and there is a 
steady enlargement, with involvement of glands in other regions. Strict 
limitation of tuberculous glands to one side of the neck or to one axilla is 
usual. A blood examination will distinguish this disease from leucaemia. 
Occasionally pseudoleucaemia merges into a lymphatic leucaemia. 

Prognosis. — The disease usually ends fatally, in acute cases in several 
months, and in chronic cases in from two to four years. Recovery is very 
rare, although periods of improvement and quiescence are not uncommon. 
Death results from asthenia, hemorrhage, pressure of the tumors, coma, 
or some intercurrent disease. 

Treatment. — In addition to every method of improving the general 
health by hygienic living, quinine, iron, and other tonics should be used. 
Arsenic is the best drug, and it may be given in gradually increasing doses 
up to the limit of tolerance. Phosphorus is probably the next best. Iodine 
internally, in five to ten drop doses of Lugol's solution after meals, is said to 
be of benefit. In the early stages, where there are only a few small glands, 
they should be removed. Local applications are of doubtful utility. X ray 
treatment may be tried. 

SPLENIC ANAEMIA 

This form of anaemia is found in infants and adults, and sometimes 
afflicts several members of one family. The anaemia is of a high grade, the 
leucocytosis is marked, the spleen is large, the liver is slightly swollen, and 
occasionally the lymph nodes are enlarged. The feature of the blood is 
the large number of nucleated red blood cells found. 

The disease seems to differ from leucaemia by the disproportionate size 
of the spleen as compared with that of the liver, by the more moderate 
leucocytosis, by the more favorable prognosis, and by the absence of 
leucaemic infiltration of the viscera. This form of anaemia is probably 
secondary. Rickets, syphilis, chronic intestinal catarrh, and chronic tuber- 
culosis have been mentioned as causes. 



382 



THE CIRCULATORY SYSTEM 



The prognosis is more favorable than in leucaemia, as size of spleen has 
no influence on the prognosis. 

Treatment. — Intestinal irrigation, hygiene, proper diet, and tonic medi- 
cation. Iron, arsenic, and any other therapeutic means which may be 
directed to any known underlying cause. 

PURPURA AND THE HEMORRHAGIC DIATHESIS 

Under these symptomatic names are included those diseases or diseased 
conditions which have the common symptom of extravasation of blood 
under the skin or mucous membrane. The chaos met with in studying 
the literature of this subject is due to our lack of knowledge regarding 
haemorrhagic manifestations. The author looks upon purpura mostly as 
an eliminative reaction of the organism to infection or autointoxication 
(intestinal toxaemia), and believes that the various forms of acquired 
haemorrhagic diathesis are due to these causes. When purpura and the 
haemorrhagic diathesis are manifest in the new-born, it is not unlikely that 
some form of infection or autointoxication of the mother has thus influenced 
the offspring. 

Pathological Varieties. — Taking this view, we should expect and do 
find the following pathological varieties: 

(a) Infectious Purpura. — In acute yellow atrophy of the liver, typhoid 
fever, pneumonia, the exanthemata, pyaemia, septicaemia, malignant endo- 
carditis, rheumatism, and malaria we may observe purpuric spots, from 
patches to ecchymoses. In typhus fever the rash is always purpuric. 
(6) Toxic. — A purpuric eruption is observed following the use of certain 
drugs, such as copaiba, quinine, belladonna, mercury, ergot, chloral hy- 
drate, and the iodides. The venom of snake bites and the poison as- 
sociated with jaundice also belong in this class, as well as the toxines 
from intestinal putrefaction (scurvy). (c) Cachectic. — Cancer, tuber- 
culosis, leucaemia, pseudoleucaemia, Bright's disease, and the debility of 
old age may cause haemorrhagic spots, particularly upon the lower ex- 
tremities, (d) Neurotic. — After fright, profound emotion, hysteria, hyp- 
notism, and severe neuralgias, vasomotor relaxations sufficient to cause 
purpura have been observed, also following the paroxysm of pain in 
locomotor ataxia. They are present sometimes in other diseases of the 
spinal cord. 

Clinical Varieties. — The ordinary clinical varieties are the following: 
Purpura Simplex. — This is seen more commonly in children, and with 
or without pain in the joints. A crop of purpuric spots appears on the 
legs, sometimes on the body or arms. Diarrhoea is sometimes present, 
and usually there are loss of appetite and slight anaemia. There is seldom 
any fever. The duration is from seven to ten days. 

Purpura Rheumatica. — (Synonyms are peliosis rheumatica and Schoen- 
lein's disease). Males are oftener affected than females, and it occurs more 
frequently between the ages of twenty and thirty. Although a history 
of rheumatism is frequently obtained, the relation of this affection to purpura 
is not understood. Usually the purpuric manifestation is ushered in by 
a sore throat, malaise, moderate fever, and multiple arthritis. The rash, 



PURPURA AND THE HEMORRHAGIC DIATHESIS 



383 



usually first appearing on the legs or about the affected joints, may be a 
simple purpura, it may show urticarial wheals, or the two combined con- 
stitute the purpura urticans. There may be nodular infiltration which 
cannot be distinguished from erythema nodosum. Occasionally vesicles 
are present, producing the pemphigoid variety of purpura (Edema is 
sometimes present, and it has been described as febrile purpuric oedema. 
The duration is usually from ten days to two weeks, but relapses are com- 
mon and the disease may occur at the same time in several successive years. 

The diagnosis is made by the association of rheumatic pains in the 
joints with purpura and urticaria. 

The prognosis is very good. 

Severe Forms. — The severe forms of purpura hcemorrhagica are known 
under various names, such as morbus maculosus (Werlhoff's disease, Henoch's 
purpura, etc.), and they are due to infection, intestinal putrefaction, and 
toxaemia. The subacute forms show a tendency to bleeding from the 
mucous membranes and into the viscera. A short period of malaise, slight 
fever, and pain in the joints precede the onset. 

Purpuric spots, in size from that of a pin head to that of the palm 
of the hand, are present. Gangrene of the skin may follow extensive ec- 
chymoses. Hemorrhages, moderate or profuse, occur from the mucous 
membranes, most frequently from the nose, the kidneys, the intestines, 
and the uterus. The abdomen becomes rigid and severe vomiting may set 
in. Internal haemorrhages into the brain and its meninges, into the lungs, 
or into the suprarenal capsules are not so frequent as in the very acute 
form. The spleen and liver may be enlarged and jaundice is not uncommon. 

The gums may be normal or rarely swollen and bleeding, but the teeth 
are not loosened, as in scurvy. We exclude scurvy by a knowledge of the 
previous health, the circumstances under which it develops, the loosening 
of the teeth, etc. The blood may show changes of anaemia. It is most 
commonly met with in young and delicate individuals, particularly in young 
girls, and in adults in the cachectic stage of chronic ailments. Scurvy in 
children and adults belongs to this group. It may be defined as an ac- 
quired hsemorrhagic diathesis due to intestinal putrefaction and toxaemia. 

The prognosis in children is usually good, but occasionally prostration 
is marked and the patient may pass into a typhoid condition and die. The 
duration is from a few days to several weeks. In cachectic adults the prog- 
nosis is less favorable, and is grave when associated with the cachexia of 
chronic renal, hepatic, or malignant disease. 

Acute, or Fulminating, Purpura Hemorrhagica. — In this form 75 per 
cent of the patients die. There is a chill, with fever rising to 103° or 104°, 
intense prostration, purpuric spots appearing rapidly, and bleeding from 
the mucous membranes. Alternating stupor, restlessness, and delirium 
supervene and the patient dies from haemorrhage or in coma in from one to 
seven days. 

Other patients may die from haemorrhages into the viscera, the brain 
and meninges, or into the suprarenal capsules, in which cases there may 
be collapse and death in a few hours. 



384 



THE CIRCULATORY SYSTEM 



Treatment. Purpura Simplex. — Attention to the mode of life and 
the surroundings, fresh air, good food, hygienic methods to restore normal 
blood conditions, and tonics. High enteroclysis, practised once or twice 
daily, is a most important aid in the management of all forms of purpura. 
A complicating haemorrhage from the bowel does not necessarily contrain- 
dicate a low bowel irrigation. Dilute hydrochloric acid, in 3 to 5 drop 
doses, should be given in sweetened water several times a day, also fruit 
acids. Arsenic in full doses seems to act best in children. No benefit is 
derived from small doses. 

Peliosis Rheumatica. — The salicylates may be given with discretion in 
the rheumatic forms, although little assistance in controlling the haemor- 
rhage is thus obtained. For the haemorrhages, aromatic sulphuric acid, 
alum, acetate of lead, gallic and tannic acids, ergot, and turpentine have been 
used. Oil of turpentine, in 10 to 20 drop doses three or four times a day, 
seems to be the best. Calcium chloride, in twenty grain doses four times a 
day for three or four days, has been advised to increase the coagulability 
of the blood. Gelatin in 2 per cent sterile solutions has been used subcuta- 
neously, internally, and locally. The suprarenal extract, employed locally 
and internally, has often acted promptly. Epistaxis and menorrhagia 
may require tamponage. Stypticin, in 3 to 5 drop doses of a 10 per cent 
solution, may be tried. The management of scurvy in children is discussed 
in the paediatric section of this book. 



Hemophilia; Hemorrhagic Diathesis; Bleeders 

The term hemophilia is used to distinguish an abnormal tendency to 
capillary haemorrhage, which may be hereditary or acquired. The so called 
"bleeders " cannot be distinguished from normal individuals by any char- 
acteristic external appearance. The bleeding may be superficial, inter- 
stitial, or into joints and cavities, and is usually of traumatic origin. The 
first manifestations are not usually seen until after the first year of life. 
Fatal haemorrhage from the gums after tooth extraction or from trivial 
wounds and fatal post partum haemorrhage are occasionally observed in 
bleeders, although the prognosis is not usually serious as regards life. 

Treatment. — Known bleeders should be cautioned as regards the risks 
of operative interference and should be encouraged to lead an out of door 
life as conducive to overcoming the haemorrhagic diathesis. Every effort 
should be made to give them a good digestion and to make the bowels 
move at least once a day, and a cold douche or a cold sponge bath should 
be added to the daily routine. 

To check bleeding we employ rest, pressure, styptics, and internal 
medication. Absolute rest in bed is essential. Splints are necessary to 
insure immobilization in case of bleeding into joints, etc. Pressure may 
be manual and by means of gauze or rubber bandages, or a pledget of ab- 
sorbent cotton soaked in alum water, or a 10 per cent antipyrine solution 
may be pressed or packed into accessible bleeding cavities, such as the 
nose, a tooth socket, or the uterus, and the actual cautery may be used to 
control bleeding points and surfaces. 



SEPTICEMIA AND PYEMIA (BLOOD POISONING) 



385 



Drugs. — Suprarenal extract, locally and internally, is highly recom- 
mended, also stypticin, of which gtt. ij to iij of a 10 per cent solution may 
be given every half hour. Other useful drugs are aromatic sulphuric acid, 
gtt. v to x ter in die; acetate of lead, gr. £ to ij ter in die; tannic or gallic 
acid, gr. ij to x ter in die; and oil of turpentine, gtt. x to xx ter in die. 
Gelatin in 2 per cent solution has been used locally, internally, and sub- 
cutaneously. Calcium chloride, in 20 grain doses four times a day for 
three or four days, has been advised to increase the coagulability of the 
blood before operations on suspected bleeders. 

Remarks on Haemorrhage, External, Internal, Visible, Invisible 

The source of a visible haemorrhage is usually easy of recognition, as in 
haemorrhage from the surface, the nose, the throat, the ear, the eye, the 
uterus (menorrhagia and metrorrhagia) , the bladder, the kidney, the stom- 
ach, the lungs, the rectum, the prostate, and the subconjunctival and sub- 
retinal spaces, etc. 

A concealed haemorrhage is one which gives no visible evidence, as in 
the thorax, abdomen, and pelvis. Haematuria in children is always the 
result of a rupture of blood vessels, and it is found under the same con- 
ditions as in adults and frequently in acute infectious diseases. To dis- 
tinguish between haemorrhage from the nasopharynx, stomach, and lungs 
is not difficult. Haemorrhage from a typhoid ulcer usually shows itself 
in the stools. The symptoms of concealed haemorrhage are those of col- 
lapse, with dyspnoea, restlessness, and often pain. The pulse is weak, 
the patient may be unconscious, and nausea and vomiting, with a rapid 
heart's action, are observed. Thus, we may have bleeding and rupture 
into the pleural or abdominal cavities (ectopic gestation and rupture, 
haematoma). 

Intracranial haemorrhage gives symptoms such as paralysis, paresis, 
aphasia, and coma. A concealed intestinal haemorrhage may follow 
an injury, and purpura and haemophilia may be the cause of various 
bleedings. 

The clinical significance and management of various regional haemor- 
rhages are discussed elsewhere. 

SEPTICEMIA AND PYEMIA (BLOOD POISONING) 

Septicaemia is produced by the absorption of septic organisms and their 
ptomaines from any open wound or focus of inflammation. . In pyemia 
we observe, in addition to general septic symptoms, the formation of meta- 
static abscesses. 

Septic intoxication is met with in obstetrical cases (see Puerperal Sepsis) 
and is occasionally observed in the wake of mild or severe inflammation of 
the nose and throat or takes its origin in small and insignificant abrasions 
of the skin. 

The symptoms are those of septic infection: Restlessness, chills, high 
temperature, nausea, vomiting, a rapid pulse, and delirium. In some fatal 
cases the temperature is but little above the normal. 



386 



THE CIRCULATORY SYSTEM 



The prognosis is grave. 

The treatment for all such conditions is identical: The portal of entrance 
should be kept clean, and abscesses must be opened and cleansed. The 
patient should breathe cold air and should receive a fever diet. Stimula- 
tion by means of enteroclysis, whiskey, and drugs is demanded (see 
General Therapeutics). Serum treatment for septic conditions is in the 
experimental stage. 



CHAPTER XIV 



THE CIRCULATORY SYSTEM — Concluded 

CLINICAL FORMS AND THERAPEUTIC MANAGEMENT OF 
DROPSY AND EFFUSION 

Synopsis: Remarks on the Clinical Pathology of Dropsy and Effusion. — Anasarca, its Man- 
agement. — Indications and Technique of Venesection. — Ascites. — Tapping. — Permanent 
Drainage, Operative Treatment. — Hydrothorax and Pleuritic Exudates. — Tapping the 
Chest. — Pericardial Fluid. — Tapping the Pericardial Sac. — Hydrocephalus. — Spina 
Bifida. — Tapping the Cranium and Spine. — Pulmonary (Edema (Acute and Subacute) . 
— Collateral Inflammatory (Edema of the Glottis, Uvula, Anterior Mediastinum, Con- 
junctiva, Prepuce, etc. — Malignant (Edema. — Anthrax (Edema. — (Edema from Poi- 
sonous Bites. — Essential Dropsy without Albuminuria. — (Edema of the New-Born. — 
Myxcedema. — Unilateral (Edema from Thrombosis and Pressure, as in Milk Leg 
Fractures, etc. — Angeioneurotic (Edema. — Encysted Dropsy. — Retention Cysts. — 
Hydatid Cysts, Hydronephrosis. — Dropsy of the Gall Bladder. — Hydrosalpinx. — 
Hydrocele, Hydrocele of the Cord. — Dropsy of the Amnion. — Ovarian Cysts. — Pan- 
creatic Cysts. — Mesenteric Cysts. — Hygroma. — Serous Abscesses. — Dropsy of Joints 
and Tendons. — Resume of Diagnostic Punctures. — Points of Puncture. — Gross Char- 
acter of Puncture Fluids. — Cytodiagnosis. 

GENERAL REMARKS; (EDEMA 

(Edema is a disturbance in the equilibrium of the inflow and outflow 
of lymph from various causes, such as venous obstruction (in the liver, 
kidneys, lungs, spleen, etc.), cardiac feebleness, pressure of tumors or exu- 
dates in the pleura or pericardium, tissue inflammation, angeioneurotic dis- 
turbances, etc. The state of nutrition of the capillaries and a peculiar 
blood composition (hydrsemia) are also factors in the production of dropsical 
phenomena. 

(Edematous swelling usually begins in loose tissue. In venous stasis 
in the thorax the pressure in the left subclavian vein (where the thoracic 
duct is situated) is increased, the flow of lymph impeded, and oedema 
favored. 

(Edematous fluid is poorer in albumin and leucocytes than lymph. 
Lymph saturating the tissues is simply a transudate from the blood, and 
finally it reenters the venous circulation through the thoracic duct. 

A serofibrinous inflammatory exudate, such as occurs in pleurisy, etc., 
is much of the nature of stasis oedema, but is richer in corpuscular ele- 
ments and fibrin than ordinary stasis oedema. 

We are occasionally unable to distinguish clinically between stasis and 
an inflammatory oedema. Thus, we find inflammatory oedema in the lungs 
in pneumonia and tuberculosis. The pulmonary oedema of nephritis is 

387 



3.88 



THE CIRCULATORY SYSTEM 



most probably a stasis phenomenon. Acute laryngeal oedema and chemosis 
of the conjunctivae are probably of the inflammatory variety. 

The general oedema of acute and chronic Bright 's disease is not alto- 
gether stasis oedema, but is the result of various factors, such as hydrsemia, 
heart insufficiency, water retention, and changes in the walls of blood 
vessels. 

The dropsies of cachexia and of central nervous disease have not been 
thoroughly cleared up. The same may be said of the so called essential 
and neurotic cedemas. Chronic oedema resulting from permanent occlusion 
of blood vessels is known as stasis oedema. 

(Edema may be symmetrical, circumscribed, or diffuse. When areolar 
tissue is cedematous, we speak of anasarca; when serous cavities are in- 
volved, we speak of hydrothorax, ascites, hydrocephalus, hydrarthrosis, etc. 

All forms of oedema should be looked upon as pathological, except per- 
haps the swelling of the ankles in persons who stand or walk much, but are 
otherwise in good health. From this variety to the " waterlogged " in- 
dividual, all forms are encountered in general practice. Dropsy in any 
form is generally a source of anxiety and apprehension to the sufferer, and 
demands the full attention of the medical practitioner. The treatment of 
dropsy is general and local with due regard to the underlying cause. 



In most diseases, organic or otherwise, which end in cardiac insufficiency 
or cachexia and hydrsemia, a dropsical condition of the body or its depend- 
ent parts will ultimately develop. This dropsical condition of the tissues 
will be more or less symmetrical, that is, affect both sides of the body, in 
contradistinction to localized oedemas due to local disturbances. Although 
cardiac dropsy usually first shows itself at the ankles, and renal dropsy 
at the upper part of the body (puffy eyelids, etc.), such phenomena should 
not be relied upon for a snap diagnosis. On the contrary, a careful clinical 
inquiry or examination must at once be made and the primary cause of 
the dropsy elicited. 



The general management of dropsy as a symptom includes tonic treat- 
ment, hydragogue cathartics, diuretics, heart tonics, "dry living," sweating, 
and venesection. 

Diuretics and heart tonics are often of great service and may be used 
as follows: 

Infusion digitalis (gr. xxx to Sjv), a tablespoonful every two, three, 
or four hours. To each bottle of infusion half an ounce of acetate of potas- 
sium and some syrup may be added. Or the following may be given: 



ANASARCA; GENERAL (EDEMA 



General Management 



~Bj, Pulv. digitalis, 
Camphorae, . . . 
Flor. benzoes, . 



gr- ij; 
gr- ij J 
gr. v. 



M. Sig. : Three to four such powders each day. 



ANASARCA AND (EDEMA OF THE LOWER EXTREMITIES 389 



Camphor is a valuable heart tonic and diuretic. Ten to fifteen drops 
of camphor in oil (15 per cent) may be given subcutaneously. Potassium 
iodide acts as a diuretic. In some cases twenty grains in two ounces of 
warm water may be administered per rectum two or three times a day. 
To prevent iodism, ten grains of chlorate of potassium may be added to each 
dose of the iodide. Diuretin, in half drachm doses, may be given four times 
a day, or five grains of benzoate of sodium and caffeine three times a day. 

The following is also effective: 

1$ Tinct. digitalis, 5ij; 

Sol. nitroglycerin! (1 per cent), 3j; 

Tinct. strophanthi, 3j- 

M. Sig. : Fifteen drops four times a day. 

In children the doses are proportionately smaller. 

Sweating in Anasarca. — Sweat boxes of all sizes and shapes are obtain- 
able. In the absence of a hot air apparatus, the patient is placed nude 
on a chair and covered with a large blanket. Underneath the chair a 
lighted alcohol lamp is placed. Hot air may also be conducted under the 
blankets while the patient is in bed, by means of a sheet iron oven with a 
spout and an alcohol lamp; or the patient may be placed in a bathtub 
closed by means of a heavy blanket, so arranged that the head is free. 
"Waterlogged " patients should live on a dry diet, and take just enough 
liquids to quench thirst. 

Water may be removed from the body by means of hydragogue cathartics, 
such as calomel, gr. x, and podophyllin, gr. J to h, or blue mass, gr. x and 
podophyllin, gr. J to ^, with the addition of aromatic powder to prevent 
griping, such a dose to be taken once a week. Another plan is to give 
sulphate of magnesium in teaspoonful doses, as follows: 1st day. One 
teaspoonful every hour until about fourteen stools are secured. 2d day. 
Rest. 3d day. Sulphate of magnesium. 4th day. Rest, and so on until 
the dropsy is gone. In some cases this treatment exhausts the patient and 
must be discontinued. Elaterin, in r V grain doses, may be given every 
3 to 6 hours for several days and the treatment continued with heart tonics, 
such as digitalis, strychnine, opium, etc. 

Venesection in Dropsy. — Whipping up the heart by stimulants, aided 
by cathartics and sweating, is effective so far as it goes. In cases in which 
the desired effect is not obtained after a reasonable time, it is useless to 
continue without at the same time relieving the heart by venesection. 
The benefits of bleeding are twofold: 1. The relief of vascular engorgement. 
2. The removal of some of the toxic products which have accumulated in 
the blood as a result of insufficient elimination from failure of the emunc- 
tories. The technique of venesection is described in the chapter on General 
Therapeutics. 

(EDEMA OF THE LOWER EXTREMITIES 

The presence of oedema in the lower extremities is not an urgent symp- 
tom, since it does not tend, like hydrothorax, to aggravate the failure of 
the circulation, the two conditions acting and reacting on one another. 
There is less necessity for tapping in oedema of the lower limbs, but there 



390 



THE CIRCULATORY SYSTEM 



are cases where it may prove of service by relieving pain and excessive ten- 
sion. Before we scarify or drain a limb it may be wise to attempt to in- 
fluence the oedema of the extremities by elevation, mild massage, or an 
elastic bandage in connection with the constitutional treatment outlined above. 

Elevation of a limb is readily secured when the patient by choice or 
necessity is confined to his room or is limited in his excursions to the veranda 
or garden. For patients who are up and about, pressure can be utilized 
to overcome oedema of the feet. The writer prefers an elastic bandage to 
the rubber stocking. The rubber roller bandage should be three inches 
wide and from four to five yards long. A thin cotton stocking, with the 




Fig. 122. — Longitudinal Scarification for (Edema. 



toe end cut off, is first put on and the bandage is evenly applied, without 
much stretching, from the toes to the bend of the knee. The bandage 
is applied on rising in the morning and taken off on going to bed. This is 
also good treatment for varicose veins. 

Massage is a valuable aid in the management of oedema, particularly 
in connection with the hot air treatment. 

Scarification and linear incision are useful methods. After thoroughly 
cleansing the skin with green soap and carbolized water, a puncture or linear 
scarification is done with an aspirating needle or scalpel, and the watery 
exudate is absorbed by a sterile cheesecloth dressing. There is always some 
risk from secondary wound infection by this method, but with great care 
this can be avoided. Fluids may be removed from punctured or scarified 
cedematous tissue by means of cupping glasses or the vacuum aspirator. 



MANAGEMENT OF ASCITES 



391 



ASCITES 

Ascites is an accumulation of fluid in the peritoneal cavity. It may 
be free or sacculated. If it is free and the patient is on his back, the fluid 
will give dulness on percussion, and the line of dulness will change with a 
change of the patient's position. If the abdomen is not well filled, its 
centre is resonant on percussion on account of air-containing intestines 
floating on top. A small amount of fluid may be made out by placing the 
patient in the knee-elbow position and eliciting dulness on percussion 
from below about the region of the umbilicus. When considerable fluid 
is present, a fluctuation or percussion wave may be elicited by bimanual 
manipulation. The character of the fluid is made out by means of the 
aspirating needle or syringe. 

Differential Points. — Pregnancy, ovarian cysts, a distended bladder, 
omental cysts, and hydatid and pancreatic cysts give dulness over the centre 
of the abdomen or wherever they are located and tympanitic resonance in the 
flanks. A free serous effusion in tuberculous peritonitis gives the same 
physical signs as ascites from other causes. 

Cysts and ascites may coexist. A laboratory examination of an aspirated 
fluid will often distinguish between ascites and ovarian cysts, but occasion- 
ally an exploratory laparotomy must be done to establish an exact diagnosis. 
Haemorrhage from a ruptured tube or ovary may give rise to physical signs 
of free fluid in the abdomen. 

In simple free ascites the history shows gradual uniform enlargement 
of the abdomen with flattened sides. The prominent navel with enlarged 
superficial veins, the fluctuation wave, the dull percussion sound as com- 
pared with the tympanitic intestinal sound, the movable dulness on change 
of the patient's position whenever sufficient free fluid is present, and the 
character of the fluid obtained by puncture, clear amber, greenish, chylous, 
or bloody, will aid in establishing the diagnosis. 

Ascites without general cedema is most commonh' due to cirrhosis of 
the liver or other portal obstruction (tumors). Ascites plus osdema is 
generally due to renal or cardiac disease. 

Management of Ascites 

If the ascites can be influenced by drugs (digitalis in heart failure, 
iodide of potassium and mercury in syphilis, or quinine in malarial spleen), 
such treatment should be adopted and reenforced by cathartics, sweating, 
massage, and general tonic management. If not, the fluid must be re- 
moved by tapping and repeated tapping in order to relieve embarrassment 
of the heart and kidneys. 

Tapping is done in the median line or the lateral aspect of the abdomen. 
The patient is placed in a comfortable armchair with a bucket between 
his feet and a rubber apron over his legs. The parts are cleansed and local 
anaesthesia is secured by means of chloride of ethyl spray or cocaine, a few 
drops of a 4 per cent solution being injected under the skin. A small incision 
through the skin facilitates the introduction of the trocar. To prevent blocking 
26 



392 



THE CIRCULATORY SYSTEM 



of the cannula by loops of intestine (after some of the fluid has come away), 
the author has devised and uses a trocar with a sievelike end. 

To prevent syncope, the fluid should be allowed to run out slowly, and 
the patient may take coffee and whiskey. When all or nearly all the fluid 
has flown out, the wound is secured by a pad of bichloride gauze and a 
strong binder, and the patient put to bed. 

Should the trocar strike a large vessel (which is a rare occurrence), and a 
free and profuse ha>morrhage ensue, the abdomen must be opened and the 
bleeding vessel secured. If the patient is comfortable after tapping, the ab- 
domen may be explored through the lax abdominal walls, and doubtful diag- 
nostic points may be made clear. Before tapping the bladder should be 
emptied. 

Permanent drainage of the abdomen for ascites was first suggested by 
the writer in 1886. A rubber catheter is introduced into the abdominal 
cavity through the cannula of a large trocar or through an incision. The 
protruding part of the rubber tube is secured to the abdomen by means of 




Fig. 123. — Tapping the Abdomen under Local Anaesthesia. (See Ascites.) 

straps of rubber zinc plaster, and the end of the tube is clamped so as to 
permit of a periodic flow or removal of fluid, or it may drain into a recep- 
tacle if the patient is compelled to remain in bed. Drainage can be kept 
up for weeks, and in the event of the establishment of a good collateral cir- 
culation, improvement of the underlying condition for long periods has 
been observed and reported. For particulars regarding this method, the 
reader is referred to the author's original communication in the New York 



PERMANENT DRAINAGE FOR ASCITES 



393 



Medical Journal, February, 1886, and to subsequent reports by others who 
have used this method. In recurrent ascites from cirrhosis of the liver 
permanent drainage is of value. The collateral circulation eventually 
established takes place by reason of the anastomoses of the portal vein 
with the superior cava and the azygos vein. 

Operative Treatment for Ascites. — The artificial establishment of vascular 
anastomosis has been attempted by attaching a piece of omentum, about 




Fig. 124. — Permanent Drainage for Ascites. (Author's Method.) 



two inches square, to the abdominal wall by catgut or kangaroo tendon 
stitches. Adjacent peritoneal surfaces over the liver have been scarified 
and made adherent, and the spleen has been fixed to the abdominal wall. 

HYDROTHORAX ; PLEURITIC EFFUSION 

Signs. — The rational signs of fluid in the chest are a feeling of resistance 
on percussion, dulness or flatness on percussion, a tympanitic percussion 
note above the fluid level, dulness on the right side, continuous with that 
of the liver, the respiratory murmur indistinct or absent (or distant bronchial 
breathing may be heard), and bulging of the intercostal spaces on deep 
inspiration. In doubtful cases an exploratory puncture may be necessary to 
establish the presence and character of the fluid. Dyspnoea is the principal 
symptom in pleuritic effusion, and displacement of the heart and crowding 
up of the lung into the apex space are often observed. 



394 



THE CIRCULATORY SYSTEM 



Thoracocentesis. — Fluid in the thorax, whether unilateral or bilateral, 

can easily be removed, but this should not be done simply because of its 
presence. Embarrassed respiration and embarrassed heart's action of a 
severe type are the indications for operative interference. Thorough cleanli- 




Fig. 125. — Exploratory Puncture of the Chest under Ethyl Chloride Local 

Anaesthesia. 

ness must be observed in the various manipulations incident to thoraco- 
centesis. The patient is stripped to the waist and made to straddle a chair 
with the arms resting on a pillow over the back of the chair. If necessary, 
the chest can be tapped with the patient sitting or reclining in bed. After 
determining that the chest contains fluid, the part selected for puncture is 
cleansed and the exact spot (seventh or eighth interspace) made anaesthetic 
by the chloride of ethyl spray or a subcutaneous injection of 4 per cent co- 
caine solution. For aspiration the author prefers the suction apparatus with 
a bottle. The patient is told not to move and assured that there will be 
very little pain (children are firmly held). The needle is then introduced. 
The operator should hold the needle loosely between the thumb and index 
finger, and the suction pump is to be worked by an assistant. Whenever 
the needle is felt to scrape the lung surface, its point should be raised or de- 
pressed, or slightly withdrawn to make it free. The patient is enjoined not 
to talk and to suppress coughing if possible. If a trocar is used instead 
of a needle, a preliminary small incision through the anaesthetized skin is 
advisable. 

When the fluid ceases to flow, or when uncontrollable coughing sets in, 



HYDROTHORAX; PLEURITIC EFFUSION; THORACOCENTESIS 395 



toward the end of the operation, the needle or trocar should be withdrawn 
and the wound secured with a compress of sublimate gauze and a binder. 
If, for any reason whatsoever, prolonged aspiration is out of the question in 
children or adults, enough fluid may be removed to temporarily relieve 
intrathoracic pressure. 

When the pleura is thick and a large trocar is used, it sometimes happens 
that the thickened membrane is stripped from the chest wall or simply 
pushed forward, in which event no fluid will flow. The trocar should be 
withdrawn and a large needle used instead. A calcified pleura makes it 
impossible to introduce a needle. Pneumothorax, subcutaneous emphysema, 
and pulmonary haemorrhage following puncture of the chest are rarely 
encountered by careful operators. After the needle is once in position, 
lateral movements of the same are to be avoided. 

In tapping the chest it is well to remember that a line drawn horizontally 
from the nipple around the chest passes over the sixth intercostal space 
midway between the sternum and the spine. This rule may prove service- 
able in stout people in whom it is difficult to count the ribs. 

Non-inflammatory hydrothorax is unilateral or bilateral in cardiac and 
renal disease or in any form of cachexia or in arteriosclerosis, etc. In 




Fig. 126. — Aspirator. 



some instances a pint or even a quart of fluid in each side of the chest will 
give but little discomfort, and need not be removed. In other cases, 
particularly in heart disease, the removal of half a pint or a pint of fluid 
will give much relief. 

The inflammatory exudates are serous, seropurulcnt, sanguinolent, or 



396 



THE CIRCULATORY SYSTEM 



purulent. Their occurrence and management are discussed in the chapters 
on Pleurisy and Pyothorax. 

Seropurulent exudates may be aspirated once, and, if they reaccumulate, 
free incision and drainage are indicated. The purulent variety is treated 
like any other abscess, i. e., by free incision, with or without resection 
of a portion of a rib, to secure good drainage. 

Pericardial effusion varies in composition and character precisely as 
does pleuritic effusion. In general dropsy, serum may be found. In in- 
flammatory pericardial effusion the fluid contains more fibrin or corpuscular 




Fig. 127. — Heat Vacuum Aspirator. 



elements, blood, and pus. As the diagnosis is discussed under Pericarditis, 
we shall speak only of the indications and method of tapping. 

Indications. — Whenever the effusion in the pericardium is so massive 
as to interfere with the heart's action and thus threaten life, it should be 
removed, be it serum, blood, or pus. Thus, we may be compelled to operate 
in violent acute cases and in chronic cases with no absorption. The in- 
strument to be used is a medium sized trocar in connection with an aspirator. 
It is not wise to employ an ordinary sharp pointed aspirating needle, owing 
to the danger of scratching or puncturing the moving heart. 

The parts are disinfected, anaesthetized, and incised as in thoracocentesis. 
The needle is introduced two inches and a quarter to the left of the median 
line of the sternum, preferably in the fifth interspace, near the junction of 
the sixth rib with the cartilage, or in the fossa between the ensiform cartilage 
and the costal cartilages of the left side. The patient should be in bed or 
sit and lean back. In counting the intercostal spaces, we must remember 
that the first rib lies under the clavicle. After the fluid has been removed 
the small wound is closed as in puncture of the chest. A careful manipula- 
tor will endeavor to avoid wounding the internal mammary artery or punc- 
turing the auricle. The admission of air should also be prevented. The 



ACUTE AND CHRONIC HYDROCEPHALUS 



397 



operation not only is palliative, but may be followed by substantial im- 
provement. If the fluid reaccumulates, the operation may be repeated. 
If pus is formed in the pericardial sac, incision and drainage are indicated 
as in pleural empyema. 

An ignition vacuum bottle for aspirating fluids was suggested by Dr. Carl 
Connell in the Medical Record for July 4, 1903. Three drachms of 95 per 
cent alcohol are poured into the bottle, which is then turned until the entire 
surface is coated. The excess of alcohol is poured off. The bottle is then 
placed upright and ignited at the mouth before the film of alcohol has time 
to dry or settle. (See Fig. 1.) A sheet of flame descends into the bottle, 
varying in time for complete ignition from a fraction of a second to several 
seconds, depending on the strength of the alcohol and the temperature of 
the glass. As the flame touches the bottom, the bottle is quickly corked. 
On attaching the needle the aspirator is complete. It may be employed 
for the aspiration of cavity fluids and tissue fluids (oedema of the scrotum). 

Aspiration from the Patient's Standpoint 

The following article on "Aspiration from the Patient's Standpoint," 
by Walter Bensel, M.D., may be of interest here: 

"Shortly after the blizzard of a few years ago I contracted a pleurisy 
with effusion from exposure during the storm. The effusion became so 
large and caused such considerable dyspnoea, dysphagia, and displacement 
of the heart that it was deemed advisable to aspirate and withdraw some 
of the fluid. The first needle that was introduced was a small hypodermic 
syringe needle, simply for diagnostic purposes. The only thing that I 
observed at this time was that the pain was much more considerable than 
I had supposed it would be. Soon afterward another, larger sized needle 
was introduced to remove the fluid, and then I noticed that there were 
two distinct sensations of pain, equal in intensity, but different in character, 
one as the point of the needle passed through the skin, and the other just 
before the fluid was reached. The second was precisely the same as the 
'stitch in the side' felt with a dry pleurisy. A reaccumulation of serum oc- 
curring in a few days, a needle was again introduced. Only a small amount 
of fluid was removed before the lumen became obstructed in some way, 
and the needle was withdrawn and reintroduced in another situation. A 
few minutes before each of these two aspirations, a 4 per cent solution of 
cocaine was injected hypodermically, so that no pain was felt as the needle 
passed through the skin. The same degree of pain occurred as before, 
however, when the needle passed through the pleura. These facts would 
seem to indicate that the pleura possesses nearly, if not quite, as great 
sensibility as the skin itself." Sloane Maternity Hospital, Decem- 
ber 16, 1891. 

ACUTE AND CHRONIC HYDROCEPHALUS; HYDRENCEPHALOID, OR WET 
BRAIN; CRANIAL AND SPINAL PUNCTURE 

Hydrocephalus is an accumulation of serous fluids within the skull. 
We distinguish internal, or ventricular hydrocephalus and external, or arach- 



398 



THE CIRCULATORY SYSTEM 



noidean, hydrocephalus. These forms may be acute or chronic and con- 
genital, acquired, or symptomatic. 

Acute Hydrocephalus is often suspected in children when, in the course 
of various diseases, cerebral excitement develops, which may be followed 
by a stage of depression terminating in death. It is found as a complication 
in eruptive fevers and infectious disease, in obstruction to the venous cir- 
culation in the cranium, as a result of traumatism or compression of the 
jugular vein, or in cardiac or renal disease. A sudden effusion, or serous 
apoplexy, is a well known clinical variety, as is also the convulsive attack 
associated with Bright's disease. As ordinarily observed in children or 
adults, there are fever, headache, photophobia, insomnia, delirium, muscular 
restlessness and contracture, convulsive stupor, and often death. 

Spurious Acute Hydrocephalus, or Hydrencephaloid (wet brain) is a 
comatose condition often seen in exhaustive infectious diarrhoeas and in 
delirium tremens. 

Chronic Hydrocephalus. — Its aetiology is not clear. Judging from the 
nature of the superabundant fluid, which is poor in albumin, it is not usually 
the product of active inflammation. Enlargement of the head and nervous 
manifestations are characteristic. The eyes are prominent, and often there 
is nystagmus of the horizontal or vertical type, also head nodding. The 
head is heavy, and the extremities are feeble, as in rickets. The children 
cannot walk or stand, and the head is elastic on pressure. Large, rhachitic 
heads may be mistaken for the hydrocephalic type, and rhachitis and hydro- 
cephalus may be combined. 

The course of hydrocephalus is slow and progressive. Spontaneous cures 
are occasionally observed. An unfailing evidence of increased intracranial 
pressure is the choked disc, as revealed by the ophthalmoscope. At times 
exacerbations of the symptoms are noticed. The special senses are fairly 
acute, but the intelligence is below normal. Some cases are of ten to fifteen 
years' duration, but many of the patients die about the first year of life. 

Treatment of Both Varieties. — In both the acute and chronic variety an 
attempt should be made to direct the therapeutic efforts to any suspected 
underlying cause. Thus, if syphilis is suspected, iodide of potassium may 
be administered per rectum, in cerebral cedema due to heart failure from 
any cause cardiac tonics are indicated, and in the chronic type all manner 
of hygienic, dietetic, antirhachitic, and blood improving measures (iron, 
arsenic, phosphorus) should be tried. 

For diagnostic purposes, and for relieving pressure symptoms, the fluid 
may be removed by tapping the cranium or by spinal puncture, although 
very little benefit results therefrom. 

Tapping the Cranium and Spine. — The hydrocephalic cranium may be 
tapped with a trocar or needle at the site of the large fontanelle, an inch 
from the median line, or by trephining in the occipital region. A deep 
vertical puncture will reach the ventricle; a puncture of moderate depth 
will reach an external fluid accumulation. From one to four ounces may 
be removed repeatedly, without observing untoward effects or marked im- 
provement. 

The puncture must be done under strict antiseptic precautions (shaved 
scalp). On removing the needle, a pledget of bichloride gauze secured by 



ACUTE AND SUBACUTE PULMONARY (EDEMA 



399 



adhesive strips should be applied or the collapsed head bound up by roller 
bandages. Injections into the cranium to set up adhesive inflammation 
are useless and may result in harm. The author has injected iodoform, 
potassium iodide, sodium salicylate, and lysol for therapeutic purposes 
into the spinal canal without observing any benefit. 

Spinal Puncture. — The back of the patient is cleansed and disinfected 
with green soap and iodoform, ether, or corrosive sublimate solution, 1 to 
2,000. With clean hands the operator introduces a boiled "antitoxine" 
needle between the third and fourth, or fourth and fifth lumbar vertebrae. 
An imaginary straight line from the crest of one ilium to that of the other 
will usually cross the desired interspace. The exact spot may be marked 
on the skin with the finger nail. The puncture is made in the median line 
in children or a little to the right of the median line in adults. The direction 
of the needle is forward and slightly upward. If fluid is to be withdrawn 
for examination in the laboratory, it should be collected in a sterile glass 
tube, which is to be sealed by means of a flame. Local anaesthesia is ad- 
visable in adults and children, and the patient must be securely held in 
the proper position in order to avoid breaking the needle or injuring deep 
and important structures. (See also Paediatrics.) 

Normal cerebrospinal fluid is perfectly clear. In meningitis it is cloudy. 
In tuberculous meningitis it is usually perfectly clear. 

The differential diagnosis between the various forms of meningitis is made 
by microscopical examination of the sediment, the culture, or the inocula- 
tion focus. 

ACUTE AND SUBACUTE PULMONARY (EDEMA 

Diagnosis. — The diagnosis depends mainly upon the presence of numer- 
ous moist or dry rales and percussion dulness of the base of the lungs, in- 
dicative of an effusion of serum into the air cells. When localized, it is 
usually inflammatory or collateral; when general, it is generally a stasis 
phenomenon. The diseases with which pulmonary oedema is most com- 
monly associated are pneumonia, acute and chronic nephritis, cardiac 
disease, acute specific fevers with circulatory failure, cerebral apoplexy and 
injuries, and cachexia from any cause. 

Symptoms. — The symptoms are dyspnoea, cyanosis, cough, frothy and 
blood-stained expectoration, a rapid pulse, a cold surface, and coma. 

A rise in temperature is usually observed in cases which respond to 
stimulants (fever of absorption). Pulmonary oedema is often mistaken 
for acute pneumonia in the early stage. This is an unfortunate mistake, 
because at this time active measures, such as are not indicated in incipient 
pneumonia, may save life. In incipient pneumonia the auscultatory 
phenomena are generally one sided. There is often localized pain, and the 
dyspnoea is not so great as in general pulmonary oedema, in which the 
auscultatory phenomena are heard over the entire chest and sometimes 
posteriorly and anteriorly up to the apex. 

The most distressing form of acute pulmonary adema is that which 
comes on quite suddenly and utterly overwhelms the patient in half an 
hour's time. The following cases, briefly told, will fairly illustrate this 
form of pulmonary oedema, which is supposed to be due to paralysis of the 



400 



THE CIRCULATORY SYSTEM 



left heart and strong action of the right heart in the presence of changes 
in the capillary walls. 

A young lady, twenty-four years of age, had contracted rheumatic 
fever and endocarditis at the age of seven. She had another attack of 
rheumatic fever at the age of twelve. She remembered having been short 
of breath since childhood, and having had to leave school at the age of 
twelve. She always felt tired and weak. At the age of twenty she had a 
severe attack of diphtheria, on which occasion the valvular heart lesion 
was diagnosticated as stenosis of the mitral valve. For four years her 
appetite had been capricious, but the tongue was clean. She suffered from 
palpitation and dyspnoea after eating. She had slept poorly for the pre- 
ceding eighteen months, complaining of palpitation and dyspnoea at night. 
During the day she was unable to lie down, on account of the palpitation, 
dyspnoea, and short, dry cough. She had to discontinue wearing corsets, and 
could not walk a block without resting. If she exercised after eating, she be- 
came nauseated and would often vomit. She was constipated and laxatives 
distressed her. Very recently she had had profuse night sweats. Her gen- 
eral appearance, however, was satisfactory and she looked well nourished. 

Her first attack of acute pulmonary oedema came on at night soon after 
she went to bed, and at the time of menstruation. Menstruation was 
usually profuse, lasting from four to seven days. The attack was ushered 
in by extremely rapid action of the heart (tachycardia). Very soon there 
was urgent dyspnoea, with cough and a sensation of constriction of the 
chest. Auscultation at this time revealed moist rales in all parts of the lungs. 
In a few hours a pink froth oozed from the mouth, and the patient became 
comatose. Toward morning consciousness returned, and a hand's breadth 
of dulness on percussion was elicited over both lower lobes (oedema). The 
temperature, which had been normal before the attack, rose to between 
102° and 103° on the following day, and gradually came down to normal 
(absorption fever). The liver was also enlarged and painful to the touch 
after the attack. The arm was partially paralyzed, and vision was cloudy. 
At no time was there engorgement in the peripheral veins. The first of 
these attacks occurred on January 5, 1888; the second in February; the 
third in May; the fourth in June; and the fifth in July. The sixth, which 
occurred in September, from 11 p.m. to 2 a.m., ended in death. 

There was no evidence of nephritis or dropsy, except a puffiness under 
the eyes on one or two occasions. The valvular obstruction and a failing 
heart muscle caused the attacks, which were invariably ushered in by sud- 
denly developing tachycardia, or "heart hurry." 

The treatment in this case was the general management discussed under 
Chronic Cardiac Insufficiency, plus the treatment of the acute attacks. 

To relieve dyspnoea, it was necessary to give morphine and opium as 
follows: 

14 Morph. sulph., gr. \; 

Tinct. strophanthi, gtt. xx; 

Spir. aeth. comp., gtt. xl; 

Aq. menth. pip., ad, 3jv. 

M.S.: A teaspoonful every twenty minutes until four spoon- 
fuls are taken. 



ACUTE AND SUBACUTE PULMONARY (EDEMA 



401 



I^ Ext. digitalis fluidi, gtt.ij; 

Tinct. opii, gtt. v. 

M. S. : For subcutaneous injection every four hours. 



1$ Morph. sulph., 
Atropin. sulph 



gr- 1; 

gr. sU- 



M. : To be used subcutaneously. 

The heart was stimulated by means of strychnine, gr. every half 
hour, or nitroglycerin, gr. or caffein. sod. benzoate, gr. iij to v, al- 

ternately, every half hour. Camphor in oil (1 to 15) was given subcuta- 
neously. Dry cups and turpentine stupes were applied to the chest, and 
ice to the heart. Oxygen inhalations had no effect. On the day following 
the attack, the patient received an enema, with general massage, and potas- 
sium iodide per rectum (gr. x twice daily). 

In other similar cases, one in a fat woman with chronic nephritis, the 
other in a woman afflicted with insufficiency of the mitral valve and addicted 
to morphine (the attack coming on four weeks after childbirth), recovery 
was prompt after venesection and heart stimulation. 

Acute pulmonary oedema is also observed in the moribund stage of 
typhoid fever and in persons afflicted with arteriosclerosis involving the 
kidney. The attacks come on after slight exertion, and subside in from 
half an hour to two hours. Dyspnoea is marked, the breathing and pulse 
are rapid, and moist rales are heard all over the lung. The lung sounds 
are dull. The distress is more intense in patients whose breathing space 
is diminished from former exudative pleurisy with adhesions, which com- 
press or bind down the lungs. The high arterial tension in these cases can 
be overcome temporarily by venesection. Morphine subcutaneously will 
relieve dyspnoea. 

The subacute forms are not so sudden in the onset and not so distressing 
in the beginning. As a type of this variety, we may mention pulmonary 
oedema with slow progressive heart failure. In some instances opium or 
morphine, by quieting a tumultuous heart, will be helpful in cases of pul- 
monary oedema in adults. In children, as in adults, sudden acute pulmonary 
oedema may occur without assignable cause. 

Inversion and artificial respiration have been successfully practised in 
such cases, with massage movements from the middle of the body toward 
the head. Children with pulmonary oedema and sound hearts have a won- 
derful recuperative power and frequently recover after having had a pulse 
of 180 and respirations of 60 for two days. 

Aseptic ergot may be employed in pulmonary oedema, wet brain, opium 
poisoning, shock, and insomnia. 




3jv; 
gtt.ij. 



402 



THE CIRCULATORY SYSTEM 



COLLATERAL, OR INFLAMMATORY, (EDEMA 

Collateral pulmonary cedema associated with pneumonic inflammation 
has been discussed. 

(Edema of the Anterior Mediastinum. — The writer has observed two such 
cases in adults, one afflicted with cancer and perforation of the oesophagus, 
the other with visceral syphilis. During life a circumscribed dulness in 
the mediastinum was distinctly made out and supposed to be due to a 
mediastinal tumor. The autopsy revealed a gelatinous, oedematous de- 
posit in the mediastinum, corresponding to the dulness observed in life. 
In the case of the syphilitic the same phenomena were observed, the dulness 
disappearing under the administration of iodide of potassium. A year later 
the same observation was made, and, the patient having died, an autopsy 
revealed a circumscribed gelatinous oedema. 

(Edema of the uvula and soft palate is seen in diphtheria, nephritis, 
etc., also in circumtonsillar abscess. It is extremely annoying. Patients 
afflicted with it complain of gagging, coughing, and pain. 

Treatment. — Ice to swallow or an ice poultice (ice and sawdust 
around the neck). Scarification of the uvula is proper in the absence of 
a septic process in the nasopharynx, or the application of adrenalin chloride 
solution. 

(Edema of the larynx, oedema of the glottis, is observed in measles, 
scarlatina, diphtheria, and retropharyngeal abscess in children and in adults 
afflicted with tuberculosis or phlegmonous inflammation of the floor of the 
mouth or neck. In nephritis cedema of the glottis is usually non-inflamma- 
tory. Noisy and stridulous breathing, cyanosis, and great fear of suffoca- 
tion are the symptoms. 

Treatment. — Ice should be given by the mouth and an ice poultice 
placed around the neck, and antitoxine must be administered when it is 
indicated. In urgent laryngeal stenosis intubation or tracheotomy is in- 
dicated. Scarification of the epiglottis with a curved bistoury sometimes 
gives relief, also painting with adrenalin chloride solution. Emetics are 
useless and dangerous in cases with weak heart. Deep seated abscess 
about the neck requires prompt surgical aid. 

(Edema of the Foreskin. — The inflammatory variety requires cleansing 
of the parts, scarifications, and moist mild antiseptic dressing. Any 
constriction present must be overcome. 

Malignant cedema of anthrax and other infections is a septic inflam- 
matory cedema due to a specific infection which culminates in the anthrax 
pustule. In tissue so affected tension must be relieved by a free incision 
to avoid necrosis of the parts. 

(Edema from bites of insects (bees, etc.) is a toxic inflammatory cedema 
which assumes formidable proportions when it occurs about the face or 
neck. It usually subsides in a few hours if cold lead lotion is applied. In 
very bad cases, however, scarification and incision to relieve tension will 
be required. 

Conjunctival cedema (chemosis) and the cedema of trichiniasis are un- 
doubtedly of inflammatory origin. 



INFLAMMATORY AND PRESSURE OEDEMA 



403 



A localized visible collateral oedema frequently points to an underlying 
inflammatory focus. (Edema of the thorax may accompany empyema. 
(Edema of the right hypochondrium is found in hepatic abscess. 

ESSENTIAL, OR TOXIC, DROPSY; DROPSY WITHOUT ALBUMINURIA; 
OEDEMA OF THE NEW-BORN; MYXGEDEMA 

Cases of general anasarca are occasionally met with, chiefly in children, 
following scarlatina, but sometimes also in adults, which exactly resemble 
cases of Bright's disease, although there is no albumin discoverable in the 
urine and no abnormal condition of the heart to account for the condition. 
These have been called cases of essential, or idiopathic, dropsy. The disease 
has met with little recognition in the general textbooks. This form resembles 
renal dropsy, and there may be hydrothorax, ascites, and vomiting. The 
mortality varies from 15 to 30 per cent. Recovery takes place after about 
six weeks. It is not known whether we have to deal with anaemia, nephritis, 
or intestinal putrefaction and toxsemia. 

Treatment. — Milk diet, syrup of iodide of iron, digitalis (infusion or 
fluid extract), and intestinal irrigation. 

(Edema of the New-Born. — In congenital oedema, often of unknown 
origin, a weak circulation is a factor as well as a symptom. When the 
entire body is affected, the child's respiration is impaired, the pulse is slow, 
the temperature is subnormal, and the patient becomes drowsy and dies. 
The prognosis in general oedema is unfavorable, in partial oedema fair. 

Treatment. — The warm water bag, an enema, and camphor subcuta- 
neously as a stimulant. Attention to the underlying cause (syphilis) and 
proper diet. 

Myxcedema. — The body appears generally swollen or cedematous, but 
the swelling is firm and inelastic and does not pit on pressure, as in other 
forms of oedema. The skin is dry and rough, the facial expression peculiar 
and stolid. The patients become irritable and suspicious, sometimes de- 
mented and comatose. This condition has some obscure connection with 
the thyreoid gland, which usually becomes shrivelled and loses its glandular 
structure. Myxcedema frequently results from removal of the thyreoid 
gland. Many cures of this peculiar malady have been observed after the 
administration of the thyreoid extract or powder in five or ten grain doses 
three times a day. This preparation may be given for a long time with 
occasional intermissions (see also Diseases of the Ductless Glands). 

UNILATERAL CEDEMA FROM THROMBOSIS AND PRESSURE 

(Edema of the foreskin by constriction results in paraphimosis. As 
soon as the constriction is overcome mechanically the oedema subsides. 
If not, scarification and the application of cold lead lotion are indicated. 

Venous thrombosis and oedema are of common occurrence after con- 
finement (milk leg), in typhoid fever, in other exhausting diseases, or from 
any form of pressure. The thrombosed vein can be felt, and the tissues 
around it are sometimes red and tender to the touch. A limb in this con- 
dition must have rest and should be elevated. It may be bandaged, but 



404 



THE CIRCULATORY SYSTEM 



not tightly. Ultimately, mild general massage will aid Nature in reestab- 
lishing a circulation. 

(Edema following fracture subsides as soon as the parts are placed and 
kept in a normal natural position and the limb elevated. 

Angeioneurotic cutaneous oedema may be of a simple variety or associ- 
ated with urticaria, erythema nodosum, herpes, or febrile purpura. The 
onset is sudden and may be accompanied by colic, vomiting, and nervous 
irritability. It is looked upon as a vasomotor neurosis. It is a local 
swelling, limited in extent and duration. It occurs more frequently in 
females than in males, and principally in neurotic individuals and also in 
women who have had their ovaries removed. It has been observed in in- 
dividuals afflicted with chronic malaria or the rheumatic diathesis. It may 
appear in any part of the body. 

Treatment. — Some cases do not respond to any form of treatment; 
in others prompt improvement follows the administration of bromide of 
potassium, arsenic, quinine, or sodium salicylate. The patient is well 
between the attacks. 

ENCYSTED DROPSY; RETENTION CYSTS; SEROUS CYSTS 

Hydronephrosis 

Hydronephrosis is a retention cyst of the kidney due to obstruction of 
the ureter from various causes (by kinking, cicatricial bands, or calculi). 
It is usually unilateral and may be congenital. It occurs in both children 
and adults. 

Symptoms. — It vn&y exist without attracting attention, or present a 
progressively enlarging tumor with dragging pain and pressure symptoms. 
It may be continuous or intermittent, and may be associated with movable 
kidney. It may be mistaken for pyonephrosis, kidney tumor, or an ovarian, 
omental, or hydatid cyst. 

Pyonephrosis gives constitutional symptoms. A bimanual vaginal ex- 
amination will show the presence of an ovarian cyst. A puncture exami- 
nation of the fluid will clear up the nature of cysts in some cases, and an 
exploratory incision may be finally necessary to make a diagnosis. 

Prognosis. — Some cases give no trouble; others are cured by spontane- 
ous rupture, and some will require surgical interference. Infection may 
change hydronephrosis into pyonephrosis. 

Dropsy of the Gall Bladder 

Dropsy of the gall bladder is usually the result of impacted stone in the 
cystic duct. In recent obstruction the gall bladder contains bile, mucus, 
or pus. In long standing obstruction the liquid is often clear, thin, or 
mucous. A distended gall bladder can usually be felt below the costal 
margin as an elastic, rounded tumor which moves with respiration. In 
obstruction of the cystic duct alone jaundice is not present. Gallstone 
crepitus may occasionally be elicited. It requires discrimination from 
movable kidney, carcinoma of the gall bladder, and empyema of the gall bladder. 



HYDROCELE, SEROUS CYSTS AND OVARIAN CYSTS 



405 



Puncture of the gall bladder should not be done unless the physician is 
ready to go on with radical treatment and to operate at once, as there is 
danger of leakage from the opening into the abdominal cavity. 

Hydrosalpinx 

When the fimbriated extremity of the Fallopian tube becomes ob- 
structed from gonorrhceal or other inflammation, hydrosalpinx may result. 
This condition is recognized when the abdomen is opened for exploratory 
purposes or operative interference in tubal disease, which is made out by 
palpation and symptoms. 

Hydrocele 

Definition. — An accumulation of serum in the tunica vaginalis of the 
testicle or spermatic cord {hydrocele of the cord). This condition may be 
congenital or acquired. A hydrocele presents a smooth swelling, usually of 
ovoid shape, and translucent when tested with a roll of paper. Old hydro- 
celes are sometimes not translucent. It gives no pain as a rule, and there 
is no impulse on coughing. 

Differential Diagnosis. — Hernias, hematoceles, and tumors of the tes- 
ticles are not translucent. In hernia the swelling extends through the 
abdominal ring. An irreducible hernia associated with hydrocele shows 
an impulse on coughing. Old hydroceles and chronic orchitis with hydro- 
cele require careful exploration. Encysted hydrocele of the cord gives a 
sausage-shaped, translucent, fluctuating swelling. 

Treatment. — Small cysts require no attention. Congenital hydrocele 
tends to spontaneous cure and does not require immediate attention. 
Tapping is performed with a boiled trocar and cannula after the parts and 
operator's hands are thoroughly disinfected. The puncture is covered with 
dry lint. Repeated tappings may become necessary, as hydrocele manifests 
a tendency to recur. 

Cure by Tapping and Injection. — After tapping, the needle remains in 
place, and twenty drops of carbolic acid in half a drachm of pure glycerin 
are injected into the sac; or tincture of iodine and water (aa, 3ss.) are 
injected and manipulated so as to bring the liquid into contact with every 
part of the interior, and it is then allowed to flow out. A radical operation 
involves incision and removal of a part of the sac and drainage under anti- 
septic dressing. 

Serous Cysts 

These occur in the kidney, ovaries, broad ligaments, mesentery, pancreas, 
etc., or in the form of spina bifida, or meningocele, cysts of the cord (hydro- 
myelus ex vacuo), and cysts in the brain. Hygroma is a cyst under the skin. 

A serous abscess is a traumatic accumulation of serum. When accessible, 
serous cysts present as fluctuating tumors. An examination of the puncture 
fluid will often help in the diagnosis of cysts. They may require incision 
and drainage or excision. 

The most important are ovarian cysts, which are often of malignant 
nature. They are made out by bimanual palpation. Tapping should not 



406 



THE CIRCULATORY SYSTEM 



be performed unless one is ready to operate. Ovarian cysts may be mis- 
taken for ascites, pregnancy, or a solid tumor. The treatment is operative. 

Hydatid Cysts 

are formed by the larva? of Twnia echinococcus. They are found in any 
tissue, but most frequently in the liver, also in the brain, kidneys, lungs, 
and pleura. The so called " hydatid thrill " may be elicited by placing 
three fingers over the fluctuating mass and percussing strongly upon the 
middle finger. The aspirated fluid is like water, of low specific gravity 
(1,006 to 1,010), and contains sodium chloride and succinic acid. Shreds 
of the cyst wall, hooklets, and scolices may be detected with the microscope. 
The symptoms will vary with the region involved. If treatment is called 
for, it is surgical. 

Dropsy of the Amnion (Hydrammos) 

may be acute or chronic. The distinguishing features are great disten- 
tion of the abdomen with increased mobility of the foetus. In acute 
hydramnios there are said to be pain, fever, rapid pulse, and dyspnoea. 
Puncture of the membranes may be necessary in such cases. 

The chronic variety may be mistaken for ascites, ovarian cysts, or mul- 
tiple pregnancy. It begins about the third or fourth month, and gives 
little trouble. Women so encumbered should wear an abdominal supporter. 
As post partum haemorrhage is an occasional complication, the necessary 
precautions should be taken. 

(Edema Bullosum of the Urinary Bladder 

On circumscribed portions of the bladder mucosa the cystoscope has 
revealed clear vesicles of various sizes in connection with symptoms of dy- 
suria, usually as an accompaniment of various local inflammatory conditions 
within the pelvis. 

Dropsy of Joints (Hydrarthros) ; Dropsy of Bursoz 

This is a serous effusion into a joint with a tendency to chronicity. It 
follows irritation from detached cartilages or joint injury, and occasionally 
it is intermittent. It is observed in the knee, elbow, wrist, ankle, shoulder, 
hip, etc., and is distinguished from articular rheumatism by the absence 
of fever and of acute pain. It is usually overcome by applying friction, 
massage, and blisters, or the continuous elastic bandage. If such measures 
fail, aspiration and drainage are indicated. 

Dropsy of Tendons; Tendon Cysts; Simple Ganglion 

Definition. — An accumulation of fluid in a tendinous sheath. 

Treatment. — Forcible rupture by a blow or pressure or aseptic puncture, 
evacuation, antiseptic dressing, and pressure. 

A compound ganglion is a chronic tuberculous process. The cyst con- 
tains " rice bodies " and should be excised if it gives trouble. 



POINTS OP PUNCTURE 



407 



RESUME OF DIAGNOSTIC PUNCTURES 

Technique. — Punctures are made with a small or large exploring needle 
and syringe. The best syringes are those of glass. The needle must be 
boiled. The skin to be punctured must be scrubbed with green soap and 
water and washed with an antiseptic solution and alcohol. The hands of 
the operator must be clean. Local anaesthesia is secured by injecting a 
few drops of a 4 per cent cocaine solution or by means of the chloride of 
ethyl spray. The puncture wound must be covered with sterilized gauze 
or sealed with collodion. 

Points of Puncture 

Pleural Cavity. — The seventh or eighth interspace below the scapula or 
wherever the percussion dulness is most marked and vocal fremitus is ab- 
sent, or where an intercostal space bulges on deep inspiration. 

Peritoneal Cavity. — Be certain of an empty bladder, and puncture in 
the linea alba below the umbilicus or lateral aspect of the abdomen over 
the area of dulness. 

Pericardial Cavity. — The fourth or fifth interspace, half an inch to an 
inch to the left of the sternal margin, or in the left costoxiphoid angle, 
passing the needle upward and backward. 

Lumbar Punctures. — Between the third and fourth or fourth and fifth 
lumbar vertebrae. 

Liver Puncture. — The seventh interspace in the midaxillary line, or 
posteriorly or anteriorly directly into the liver dulness. 

Spleen Puncture. — In an intercostal interspace over the area of spleen 
dulness. 

Cranium Puncture. — Through the large fontanelle some distance from 
the middle line, in order to avoid the superior longitudinal sinus, or any- 
where through an opening in the skull made by the trephine. 

Cyst and Abscess Puncture. — At the prominent point or in the centre of 
dulness. 

Examination of puncture fluids must be carefully done in the labora- 
tory. The following are some of the gross characteristics of puncture fluids: 

Dropsical fluids, or transudates, cannot always be readily distinguished 
from inflammatory fluids, or exudates. Both are serous, clear, and of a 
light yellow or greenish color, and both contain albumin. If the specific 
gravity is under 1.015, and the percentage of albumin less than 2 .5, it speaks 
in favor of transudates. 

Bloody pleuritic exudates are frequently due either to tuberculous or to 
carcinomatous disease of the lungs or pleura. 

Seropurulent, putrid, and purulent fluids are of inflammatory origin. 

Chylous fluids are found in the abdomen, rarely in the thorax, in connec- 
tion with a parasitic invasion of filiaria, or in cancerous or fatty degeneration 
of glands and endothelial cells, or from rupture of the ductus lymphaticus. 
Chylous ascites occurring in patients on a strict milk diet may be due to 
the excess of fat in the blood (lipsemia). 

The cerebrospinal fluid, when cloudy, speaks in favor of meningitis. In 
injury to the spine the fluid may be bloody. Pure pus is sometimes found. 
27 



408 



THE CIRCULATORY SYSTEM 



Pancreatic cyst fluid presents no noteworthy gross difference fiom any 
other. It may be tested for its power of digesting egg albumin (biuret 
reaction, see Laboratory). 

Hydatid cyst fluid is colorless and clear. Hooklets, scolices, sodium 
chloride, and succinic acid may be found. 

Distended gall bladder fluid may be viscid or colorless or contain bile. 

Hydronephrosis fluid is watery, usually contains urea, and many show 
renal epithelia. 

Ovarian cyst fluid varies in color and consistence. It may be wateiy, 
viscous, or colloid and greenish or brownish in color. It is said to contain 
metalbumin. 

Cytodiagnosis . — For the cell diagnosis of puncture fluids, see Clinical 
Laboratory Methods (p. 52). 



CHAPTER XV 



THE RESPIRATORY SYSTEM 

THE UPPER RESPIRATORY TRACT 

Synopsis: Remarks on the Clinical Pathology of Respiration. — Methods Employed in Ex- 
amining the Respiratory Organs. — Rhinological and Laryngological Memoranda. — 
Catching Cold. — Nasal Obstruction. — Pharyngitis. — Laryngitis. — Simple Erosions and 
Ulcers. — Syphilis of the Nose, Pharynx, and Larynx. — Tuberculosis of the Nose, 
Pharynx, and Larynx. — Benign and Malignant New Growths. — Foreign Bodies in the 
Upper Respiratory Tract. — Haemorrhage from the Upper Respiratory Tract. — Nasal 
Deformities, Septum Deviation, Enlargement of Turbinated Bodies. — Disease of the 
Accessory Sinuses. — Diseases of the Tonsil and Lingual Tonsil. — Circumtonsillar Ab- 
scess. — Respiratory Obstruction. — Neuroses and Paralyses of the LTpper Respiratory 
Tract. — Hay Fever. — Formula? for Office Treatment. 

REMARKS ON CLINICAL PATHOLOGY OF THE RESPIRATORY TRACT 

The life of the cells and of the organism depends upon the absorption 
of oxygen and elimination of carbonic dioxide. This gas exchange we may 
call in a broad sense respiration. External respiration takes place in the 
lung, internal respiration takes place in the various other tissues. As a 
prime condition of life, pure air must have free access to the lung, and Nature 
attempts to expel foreign elements in the respiratory tract by the coughing 
effort and by means of a centrifugal propulsive power of the ciliated epithelia 
of the trachea and bronchi. 

The natural secretion of the mucous lining of the respiratory tract also 
aids in the expelling process, as do the sense of smell and the act of sneezing 
and coughing. Any marked disturbance of this complicated mechanism 
will favor infection or inflammation, be it localized in the nasopharynx, 
larynx, trachea, bronchi, or lungs and pleura. 

Cough is a reflex phenomenon transmitted through the vagus nerve. 
The act of coughing is composed of a deep inspiration and an expulsive 
expiration, with a momentarily closed glottis. The rush of air is due 
to the high pressure in the lung during the act of coughing. 

The centre for the act of coughing is located in the medulla near the 
centre of respiration. It is not known whether or not cough can be incited 
by direct cerebral irritation, but the impulse to cough is increased or dimin- 
ished by various pathological conditions of the respiratory tract itself and 
changes in the sensory as well as the motor respiratory apparatus modify 
the power to cough (weak cough in muscular inertia). A weak cough in 
young infants and feeble, aged people allows of undue accumulation of 
secretion in the lungs, with great danger to life. Inactivity of the respira- 

409 



410 



THE RESPIRATORY SYSTEM 



tory functions, as well as inactivity of the gastrointestinal tract, means 
stagnation and danger. 

Abnormal irritation with undue and fruitless cough is also a danger, 
harassing the patient, destroying the elasticity of lung tissue (emphysema), 
and producing undue arterial pressure. 

The normal oxidation process in the lungs is interfered with whenever 
there is obstruction in the nose or windpipe. Nasal obstruction means 
mouth breathing with its sequelae. Nasal obstruction in young infants 
interferes with the sucking power and with nutrition. 

Respiratory obstruction in the larynx and trachea, of whatsoever nature, 
is of grave importance, be it acute (pseudocroup, spasmus glottidis, attacks 
of whooping cough) or of a more chronic nature (tumors, membranes, 
compression from without, etc.). Under such conditions, the blood becomes 
overcharged with C0 2 and respiratory disturbances take place owing to 
the active play of respiratory muscles against atmospheric pressure, an 
inspiratory depression in the epigastric, jugular, and other regions is in- 
duced, inspiration and expiration are prolonged, and there is noisy respira- 
tion as a phenomena of such conditions. When the obstruction is due to 
paralysis of the postici muscles (openers of the glottis), inspiration is 
difficult and expiration is free. In unilateral bronchial obstruction, as 
in membranous croup, auscultation shows diminished respiratory murmur 
on the affected side. The subjective distress is greater in acute obstruc- 
tion than in that of slow onset. 

As a type of general respiratory obstruction we may mention bronchial 
asthma, also hay fever. The pathology of the asthmatic attack has not, 
however, been cleared up, notwithstanding the vast amount of study as 
to its nature. Nerve degeneration or paralysis is frequently the cause 
of immobility of the thorax and lung. Abnormal respiratory phenomena 
frequently take their origin in the respiratory centre in the bulb (Cheyne- 
Stokes respiration) and may be due to autointoxication (ursemia, diabetes) 
or to foreign intoxication (hydrocyanic acid) or to reflex irritation (asthma 
dyspepticum et uterinum). 

Respiration is also interfered with in consequence of inflammatory 
changes in the lungs or accumulations of fluid in the air cells and in the 
thoracic cavity (hydropyopneumothorax, atelectasis of the lungs, tumors). 
Abnormal chemical and physical conditions of the lung epithelia and vari- 
ations in atmospheric conditions, such as diminished or increased air pressure, 
have a marked influence on breathing and tissue oxidation (mountain 
sickness). 

Variations of atmospheric pressure influence tissue oxidation by means 
of a self-regulating process through the agency of the oxyhemoglobin of 
the blood. Thus blood pressure, quality of blood, and the degree of its 
circulation are all of great importance for respiration. 

Tissue respiration, or internal respiration, is the exchange of gases 
between the blood and the tissues. In anaemic persons the oxygen of the 
blood is diminished; thus, we notice a marked dyspnoea on exertion. A 
primary disturbance of internal, or cell, respiration may take place in con- 
sequence of changes in the parenchyma of cells or owing to toxic substances 
being contained in the circulating fluids (carbonic acid gas, phosphorus, 



EXAMINATION OF THE UPPER RESPIRATORY TRACT 



411 



hydrocyanic acid) ; moreover, the medulla is extremely sensitive to faulty 
metabolism (suboxidation or toxaemia). 

Respiratory disturbance is accompanied by a disagreeable sensation 
called dyspnoea and an indefinite vague sensation of pain which is difficult 
to localize clinically. Sufferers from chronic dyspnoea eventually reach 
a certain stage or degree of tolerance, particularly during muscular rest. 

The respiratory tract is the portal of entrance for many infectious 
diseases, and all abnormal conditions of its lining favor infection. For 
methods of prophylaxis, see the chapter on Nasopharyngeal Toilet. 

Aside from local causes, hypersemia of the upper air passages may 
result from abuse of alcohol and tobacco, cardiac, renal, hepatic, or pulmo- 
nary disease, pressure of a goitre or mediastinal tumor, gastroenteric disease 
pleuritic exudates, tympanites, constipation, constitutional disease, and 
chronic infections. 

Nose and throat symptoms in anaemic, chlorotic, and neurasthenic sub- 
jects are seldom remedied by local treatment alone. 

To sum up from a clinical standpoint, we find that, apart from malfor- 
mations and injuries, the various disturbances of the respiratory organs 
take their origin in transitory congestive conditions, in infection, and in in- 
flammation. We encounter obstructive phenomena due to foreign bodies, 
swellings, tumors, and parasites, and we frequently encounter haemorrhage 
and neurotic affections. 

RHINOLOGICAL AND LA RYNGO LOGICAL MEMORANDA 

EXAMINATION OF THE UPPER RESPIRATORY TRACT 

To illuminate the cavities to be examined, sunlight or artificial light 
is reflected by means of a head mirror. Phillips's electric headlight is con- 
venient and can be worked by the street current and current controller. 
A very convenient and portable source of light is a condenser with a re- 
flector attached (McKenzie light). The source of light should be to the 
right of the patient, a trifle higher than the mouth. In examining the 
mouth and pharynx the patient's tongue is depressed with a glass spatula 
or a spoon handle. 

In examining the larynx and trachea the patient's tongue is held with 
the left hand and the light is thrown upon a warmed laryngeal mirror. 
The distance from the laryngeal mirror to the vocal cords is about two 
inches and a half. The posterior aspect of the soft palate or vomer must 
not be overlooked, as it is occasionally the site of ulcer, etc. To secure 
relaxation of the soft palate, the patient must breathe quickly through 
the nose or make a nasal sound. Anterior rhinoscopy is practised by means 
of a hollow speculum. 

In order to allay sensibility and subdue obstructing erectile tissue in 
the nose which interferes with the vision, we apply a mixture of equal parts 
of cocaine solution, 10 per cent, and suprarenal solution, by means of a 
cotton carrier. In order to avoid constitutional effects, the solution should 
be used carefully and sparingly. 

Gargling with potassium bromide solution (5 per cent) or spraying 



412 



THE RESPIRATORY SYSTEM 



sparingly with cocaine solution (2 per cent) will subdue intolerance and 
irritability. For examining the nasopharynx, a palate hook is a convenient 
accessory. A digital examination is readily made in children with the 
index finger, nail side up. The epiglottis in children can readily be seen by 




Fig. 128. — Examination of the Anterior Nose by Means of a Nasal Speculum 

and Reflected Light. 
The light should be on the right side of patient. 

depressing the tongue, and by means of an epiglottis lifter the larynx may 
be rendered visible. 

In difficult or obscure cases an examination by means of transillumination 
and Rontgen rays is indicated. 

Autoscopy and Tracheoscopy 

In tracheoscopy the patient is examined with the head erect and high. 
In favorable cases the trachea and bifurcation and several rings of the 
bronchi can be seen. 

In examining the upper air passages one should bear in mind that 



CATCHING COLD 



413 



congestive conditions are not only due to local lesions or disturbances, 
but are frequently associated with constitutional troubles or obstruction 
to the circulation in regions far from the respiratory organs, therefore 
local treatment has its limitations. 

An examination of the deep respiratory organs embraces the various 
methods of physical diagnosis. The recognition of fluid within the chest 
is best accomplished by puncture. Exploratory incisions will probably be 
done in this region in the future by means of Sauerbruch's apparatus, un- 
der suction. The fluoroscope and x ray prints also aid us in diagnosis. 

Catching Cold 

A " cold " is an everyday occurrence concerning which a satisfactory 
explanation has not as yet been advanced. Areas of minor resistance 
or irregularities of capillary circulation are inherent or brought on in vari- 
ous individuals. If cold feet produce catarrh of the upper air passages, 
or hair cutting an angina or 
amygdalitis, the irritation is re- 
flected or transmitted to the area 
of minor resistance, and the re- 
sulting local hypersemia favors 
infection or the invasion of such 
microbes as happen to be pres- 
ent, though latent. It is a 
well known fact that the mouth 
and upper air passages harbor 
microbes at all times, and chill- 
ing of the body destroys the 
antibodies in the blood and fav- 
ors infection. In this manner 
we probably contract " colds " 
of the upper air passages. 

Breathing cold air is not of 
itself a source of danger. Nan- 
sen, the Arctic explorer, reports 
the absence of " colds " among 
his officers and crew while in 
the ice region, whereas almost 
all contracted " colds " upon 
their return to civilization. The 
writer and a number of his 

friends have been exposed to Fig. 129.— Laryngoscopy and Posterior Rhi- 

cold and damp weather for noscopy. 

Weeks On moose hunting expedi- The light should be on the right side of patient, 

tions in Canada without con- 
tracting cold, whereas two days after the landing of the party in the dusty, 
hot streets of New York City in September almost all had contracted the 
ordinary nasopharyngeal catarrh, or "cold." 

On the other hand, lumbermen in the North and Northwest, who spend 
the night in an overcrowded and overheated lumber camp, and farmers, 




414 



THE RESPIRATORY SYSTEM 



who spend most of the winter in overheated and ill ventilated rooms, are 
very apt to suffer from all kinds of infectious respiratory ailments. And 
similar "house infections" are in evidence in the cities, in barracks, in 
school rooms, and in overheated and carpeted and cushioned living apart- 
ments among the rich and poor alike. 

It is at all times difficult and frequently impossible to escape infection 
of some kind or other, but the time is ripe for abandoning the superstition 
and ignorance which invite infection by fostering and perpetuating the 



fear of breathing cold air. The usual precautions against " catching cold " 
need not be neglected. 

The predisposing causes to " colds " anywhere are breathing foul air 
(in crowded places of amusement, churches, and overheated apartments), 
breathing of dust laden air, cold feet, and exposure to draughts when 
sitting still. 

Ancemic, undernourished, overworked, and worried individuals and those 
afflicted with chronic ailments are predisposed, for in many chronic ailments 
the mucous membranes have lost their integrity and are prone to admit 
infectious material into the system. A cold, according to its localization, 
is called rhinitis, pharyngitis, laryngitis, tracheitis, or bronchitis. 

The symptoms of " colds " are the general symptoms of infection, such 
as chilliness, headache, fever, thirst, general aching, and herpes of the 
mouth and lips, associated with symptoms of local irritation, such as sneez- 
ing, running of the nose, pain in swallowing, stiff neck, hoarseness, aphonia, 
a tickling sensation, cough, and expectoration. 

Prophylaxis. — Persons liable to " colds " should wear thin underwear 
(cotton or linen) all the year round and keep warm in cold weather by 
wearing thick stockings and heavy outer garments. Daily cold sponge baths 
are advisable, and a free movement of the bowels should take place once a 
day. The nasopharynx should be free and clean. The sleeping room 
should be cold, with the windows open at the top. 

Treatment of "Colds" in Adults. — The best way to "break up a cold " 
is to go to bed after taking a hot soda foot bath and clearing the intestines 
by a brisk cathartic: 




Podophyllin, 
Calomel, ) _ _ 




gr. vhj; 



Pulv. aromatic 



gr- ij. 



M. 



During the day cold water may be taken ad libitum to promote diaphore- 
sis. The second night a dose of Dover's powder may be taken to induce 



NASAL OBSTRUCTION 



415 



sweating. A warm bath may be taken at any time, and a liquid or fever 
diet is indicated. A few drops of dilute hydrochloric acid after eating will 
aid digestion and hasten convalescence. As soon as the fever has abated, 
the patient may leave his bed and exercise moderately out of doors. 

In acute rhinitis the nasal mucosa may be so swollen as to interfere 
with breathing, and considerable relief may be obtained by applying vasel- 
ine to the nose internally and externally. (See also Office Formulae.) 

In acute pharyngitis salt water is to be dropped into each nostril and 
used as a gargle every three hours, and a cold compress may be worn around 
the neck over night. 

In acute catarrhal laryngitis the constitutional symptoms are mild. 
Examination shows a reddened and swollen laryngeal mucosa and pinkish 
vocal cords. In subacute cases lasting more than a few days the entrance 
to the larynx may be mildly cauterized by means of a cotton carrier dipped 
in 2 per cent nitrate of silver solution. Inhalations of all kinds of mild an- 
tiseptic liquids are used and probably do no harm. A dose of codeine or 
heroin at night will allay harassing cough in adults. Five to ten grains 
of Dover's powder will induce diaphoresis. In extreme cases, with attacks 
of suffocation and cyanotic skin, o?dema of the glottis or membranous ob- 
struction may be suspected. In acute tracheal catarrh there is pain behind 
the sternum. The treatment is the same as for acute catarrh of any other 
division of the upper respiratory tract. 

Perichondritis laryngis is seldom primary (infectious or traumatic), but 
generally secondary to syphilis, tuberculosis, or cancer. Although pain, 
hoarseness, cough, dyspncea, and fever may be present, the diagnosis be- 



comes certain when an abscess forms and breaks or is opened and necrotic 
cartilage is felt by probing. 

In the way of treatment we may apply ice or leeches in the early stage 
and open the abscess as soon as it presents. Tracheotomy may be neces- 
sary in acute and chronic stenosis, with subsequent intubation and dilat- 
ing by means of bougies. 

NASAL OBSTRUCTION 

Chronic nasal catarrh means nasal obstruction or syphilis. With the 
advent of the nose and throat specialist the term " chronic catarrh " has 
disappeared, and in its stead we have the various causative factors of catarrh, 




Fig. 131. — Sphay Tubes. 



416 



THE RESPIRATORY SYSTEM 



classified and treated as separate disease conditions. This is undoubtedly 
more exact as regards the anatomical location of nasal obstruction. 

Symptoms. — The general symptoms of nasal obstruction are interference 
with nasal respiration, a feeling of fulness in the nose, often alternating; 
mechanical results, such as headache, mouth breathing, a dry tongue, a 
nasal voice, vertigo, ear trouble, hawking and spitting, a nasal discharge, 
unilateral or bilateral, and various reflex phenomena. 

Causes. — The causes of nasal obstruction and nasal catarrh are hyper- 
trophic rhinitis, atrophic foetid rhinitis, deviated septum and spurs, enlarged 
turbinated bones, polyps and tumors, syphilis, tuberculosis, and foreign 
bodies. 

Hypertrophic Rhinitis 

Hypertrophic rhinitis may be defined as a swelling of the erectile 
tissue of the nose. This tissue is found anteriorly on the middle and 
inferior turbinated bones and on the anterior and upper aspect of the 
septum. A pathological or undue swelling of this tissue results from 
circulatory disturbances, from dust breathing, and usually from a ste- 
nosis of the nose due to deviations and spurs of the 
septum which produce rarefaction of air back of the 
stenosis. 

Diagnosis. — Catarrhal symptoms and the fact of 
shrinkage of erectile tissue under cocaine solution (5 
per cent) applied by means of 
cotton on a probe establish the 
diagnosis. 

Treatment. — In addition to 
general hygienic management, 
frequent cleansing and lubricat- 
ing the nose by means of salt 
water, Seder's tablets in solu- 
tion, and the benzoinated albo- 
lene spray will often give relief. 
In severe cases operative meas- 
ures are necessary. After anaesthetizing the parts by means of cocaine 
(10 per cent solution), cauterization with trichloracetic acid is performed 
once or twice at an interval of eight days, and superabundant tissue may be 
removed with the Jarvis cold snare. (For nasal obstruction due to adenoids 
or enlarged tonsils, see Paediatrics.) 




Fig 132. — Albolene Atomizer. 



Chronic Pharyngitis 

Chronic pharyngitis may be hypertrophic, follicular, granular, or atrophic, 
and is usually a part of a chronic nasal • obstruction observed in drinkers, 
smokers, and persons exposed to dust. The throat is duskily hyperaemic 
or studded with a number of projecting rounded bodies (enlarged mucous 
follicles) or shows a raw granulation tissue sometimes extending laterally 
downward. Occasionally the mucous membrane is dry and glistening 
(atrophic form). 



CHRONIC LARYNGITIS 



417 



Symptoms. — Dryness, hawking, and spitting of a tenacious secretion, 
the sensation of a foreign body, easily fatigued voice, a tendency to ear 
trouble, pain, and other nervous symptoms. 

Treatment. — (Hypertrophic form): General hygiene, avoidance of dust 
and smoking, keeping the bowels open, nasopharyngeal toilet with salt 
water, Dobell's solution, borax and glycerine, or albolene spray. Granu- 
lations are to be cauterized with 5 to 10 per cent nitrate of silver 
solution several times a week by means of a bent cotton carrier, which may 
also be inserted upward behind the uvula and soft palate. Curettage of 
the nasopharynx may become necessary, also the removal of enlarged tonsils 
or nasal obstruction. In children a chronic pharyngitis is usually due to 
adenoid vegetations, which require removal by curettage (see Adenoids). 

Chronic Laryngitis 
In chronic laryngitis we must look for the following conditions: Chronic 
laryngeal catarrh, atrophic laryngitis, pachydermia laryngis, tuberculous 
laryngitis, syphilitic laryngitis, and prolapsus 
ventriculi. 

Chronic Laryngeal Catarrh. — The aetiology is 
the same as in acute catarrh, and the chronic 
stage may follow acute 
attacks or the abuse of 
alcohol and tobacco 
and public speaking, or 
result from chronic na- 
sopharyngeal disease. On examination the 
larynx appears red and swollen and may show 
granulations and superficial ulcers or erosions. 

Symptoms. — The voice is hoarse and harsh, 
and there is cough with a thick secretion. 

Treatment. — Correction of bad habits, rest 
of the voice, correction of obstruction, benzoin- 

ated albolene spray, the nasopharyngeal toilet, vibratory massage of the 
larynx, and residence in dust free air. 

Laryngeal Ankylosis of the Cricoarytsenoid Articulation. — The majority 
of cases are due to perichondritis resulting from syphilis, gout, tuberculosis, 
typhoid ulceration, diphtheria, or any local inflammation or injury. 

Symptoms. — Hoarseness, pain, dysphagia. 

Diagnosis. — On examination, the one side of the larynx is found to be 
immovable. The differential diagnosis between paralysis of the recurrent 
laryngeal nerve and laryngeal ankylosis rests upon a careful process of 
exclusion. 

Treatment. — In chronic cases vocal gymnastics and vibratory massage 
are to be employed in connection with specific medication when indicated. 
Nasal stenosis is a frequent cause of laryngeal congestion and requires 
proper treatment when present. 

Pachydermia Laryngis. — Hyperplasia and horny metamorphosis of epi- 
thelium of the vocal process and interarytsenoid space. This condition 
is associated with chronic laryngitis and is treated in the same way. 




Fig. 133. — Snaring Posterior 
Nasal Hypertrophics. 



418 



THE RESPIRATORY SYSTEM 



Prolapsus Ventriculi. — This is a term used to designate a pendulous, 
tumorlike swelling protruding from the ventricle of Morgagni and hanging 
down into the glottis. It is a tissue hyperplasia associated with chronic 
laryngitis and may require endolaryngeal removal. 

Atrophic Forms of Rhinitis, Pharyngitis, and Laryngitis 

Atrophic Rhinitis (simple and fcetid) may be defined as an infectious 
destruction of the glandular elements of the mucous membrane. 

Symptoms. — Crust formation in the nose, offensive odor, headache, loss 
of smell, and pharyngeal irritation. 

Prognosis. — The offensive odor can be overcome; a radical cure is 
seldom observed. 

Treatment. — In addition to general hygienic management, cleansing 
with 5 per cent ichthyol spray or listerine in water, 1 to 4, or salt water, 
to be followed by benzoinated albolene spray. When syphilis is the under- 
lying cause, iodide of potassium should be administered per rectum or 
internally. 

In atrophic pharyngitis we have the symptoms of chronic pharyngitis. 
In this ailment caustics are not to be employed, as they generally aggravate 
the condition. The aqueous solution of borax and glycerine, in spray form, 
is well adapted for local use. (See Formulary.) 

Atrophic catarrhal laryngitis is observed in atrophic disease of the naso- 
pharynx. Owing to crust formation within the larynx, the voice is altered, 
dyspnoea sets in at night, and cough is present. The treatment is the same 
as in chronic laryngitis. 

EROSIONS AND ULCERS IN THE UPPER RESPIRATORY TRACT 

Superficial Simple Ulcers and Erosions are found in the nose, particularly 
in the anterior region of the septum, and frequently give rise to troublesome 
nose bleed. In the pharynx and larynx they occur in connection with chronic 
pharyngitis and laryngitis, typhoid fever, and other infections, and in 
diabetes and other chronic constitutional ailments ulceration is occasionally 
observed. 

The treatment must be in harmony with the underlying cause, and 
local if the part is accessible. The ulcerated tissue may be stimulated to 
healthy action by cauterization with a 10 per cent silver nitrate solution, or 
with the galvanocautery. The severe forms of ulceration are due to syphilis, 
tuberculosis, or carcinosis. 

Syphilis of the Nose may be congenital or acquired. Primary chancre 
is rare. The differential diagnosis from non-syphilitic lesions requires 
careful search for the various syphilitic manifestations to be found in differ- 
ent parts of the body. 

Nasal syphilis is accompanied by chronic catarrh, fcetid odor, necrosis 
of bone or ulceration of soft tissues, and pain in the nose, eyes, forehead, 
and deep structures. A softening ulcer appears as a crateriform excavation, 
frequently on the cartilaginous septum, perforation and collapse of the 
septum resulting. When the bony parts are perforated, syphilis may be 



EROSIONS AND ULCERS IN THE UPPER RESPIRATORY TRACT 419 



diagnosticated without hesitation. The perforation may extend to the 
mouth, and portions of the hard palate may come away. 

Treatment. — Syphilitic coryza in children disappears after vigorous an- 
tisyphilitic treatment: Calomel (gr. T V to I) twice daily and general hygiene. 
In adults an inunction cure or injection cure or mixed internal treatment 
is indicated, in addition to general hygiene and disinfecting nasal sprays. 
Crusts, granulations, and loose bone must be removed in the usual way. 

Syphilis of the Pharynx is usually a secondary manifestation and rarely 
a primary infection. The mucous patches appear about the time of the 
skin eruption. When an infiltration or gumma breaks down, we observe 
deep, craterlike ulceration, surrounded by a reddened zone. In the absence 
of definite symptoms a therapeutic test will decide the question. 

Treatment. — Specific local cleanliness by means of the nasopharyngeal 
toilet is valuable in the management of such conditions. In the second 
stage mixed treatment is to be adopted, and in the third stage potassium 
iodide should be given. For local treatment we employ the nasopharyn- 
geal toilet and a chlorate of potassium gargle, also cauterization with a 5 
per cent nitrate of silver solution. Adhesions between the soft palate and 
pharynx must be cut with a rectangular knife and kept open. 

Syphilis of the Larynx. — About 3 per cent of syphilitic patients are said 
to acquire laryngeal syphilis in the form of erythema, mucous patches, 
gummata, and ulcers. Syphilitic ulcers have deep red surroundings and 
spread more rapidly than tuberculous ulcers, and are apt to end in stenosis, 
owing to widespread destruction of the parts and cicatrization. 

The symptoms are the same as in tuberculous ulceration, but there is 
much less discomfort and pain. 

The diagnosis is based upon a history of syphilis and evidence of syphilis 
in other parts and the described local manifestations. Errors of diagnosis 
are possible. The writer remembers one case, which was pronounced 
tuberculosis of the larynx because tubercle bacilli were found in the sputum, 
that cleared up entirely under mixed treatment. 

Treatment. — Energetic antisyphilitic management, supplemented by 
mild local measures in the form of oil or alkaline sprays or stimulating 
inhalations, is indicated. In oedema of the larynx tracheotomy may be 
necessary. 

Tuberculosis of the Nose is seldom primary, but appears as a granulation 
tumor or ulcer, most frequently on the cartilaginous septum, which may 
become perforated. Crusts and epistaxis draw attention to the visible 
lesion. Pain is seldom complained of. 

Treatment. — Curettage and cauterization with lactic acid or the gal- 
vanocautery or radical removal of the diseased cartilage. Tuberculous 
ulcers in the nose show very little tendency to heal under any form of 
treatment. 

Tuberculous infiltration and Ulcers of the Pharynx have irregular and 
undefined boundaries with a tendency to lateral extension. 

Symptoms. — Severe pain on swallowing, a tenacious discharge, foul 
breath, hectic fever, and other evidence of tuberculosis (tubercle bacilli 
in the sputum). 

Treatment. — General hygienic treatment. Nasopharyngeal toilet, in- 



420 



THE RESPIRATORY SYSTEM 



sufflation of iodoform or orthoform, local applications of cocaine, also lactic 
acid (20 to 30 per cent). 

Prognosis. — Few cases are known to be cured. Death may ensue after 
six to eight months. 

Tuberculous Laryngitis. — About 30 per cent of persons afflicted with 
pulmonary tuberculosis have laryngeal tuberculosis. The primary involve- 
ment of the larynx is rare. Examination shows infiltration and ulceration 
in localized areas. The ulcers are usually multiple with a tendency to 
coalesce and not to penetrate deeply. (Edema of the larynx is a common 
complication. Anaemia of the larynx and pharynx is usual. 

Symptoms. — Hoarseness, aphonia, pain 
on swallowing, cough, haemoptysis. 

Treatment. — In addition to the general 
hygienic management and rest of the voice, 
the larynx should be sprayed with an alka- 
line mixture (Seder's tablets) or a watery 
liquid containing menthol, creosote, or co- 
caine. Insufflations of orthoform and iodo- 
form are to be used. In suitable cases the 
infiltration may be excised or curetted and 
the ulcer treated with 25 per cent lactic 
acid solution applied by means of a cotton 
carrier. Local treatment, on the whole, is 
unsatisfactory. Tracheotomy may be nec- 
Fig. 134.— Fibroma of the Vocal e ssary in oedema with urgent stenosis. 

Cord (Shurly). Carcinomatous Ulcers have been ob- 

served in all the mucous membranes. In 
suspected cases the patient should have the benefit of the doubt and 
undergo an inunction course for syphilis. 




NEW GROWTHS, BENIGN AND MALIGNANT, OF THE UPPER 
RESPIRATORY TRACT 

The Benign Tumors are polyps, papilloma, fibroma, lipoma, chondroma, 
angeioma, and cysts. 

The Malignant Tumors are carcinoma and sarcoma. 

New Growths in the Nose 

Polyps are soft gelatinous masses, and if located anteriorly they can 
be seen to move with each breath. Those growing in the posterior nares 
may be detected by introducing the finger behind and around the soft 
palate, or they may be engaged in a wire loop introduced through the anterior 
nares. The symptoms are those of unilateral or bilateral obstruction, with 
"catarrh." Neoplasms of the pharynx are not frequent. We observe them 
on the uvula, palate, tonsils, and other parts of the pharynx. Naso- 
pharyngeal polyps and fibromata may arise from the vomer, the choanae, 
and the occipital bone. 

Treatment. — Polyps are removed by means of a forceps or the wire snare, 
and if possible under cocaine. The base of the polyp, after removal of 



BENIGN AND MALIGNANT GROWTHS 



421 



the growth, should be cauterized with trichloracetic acid to prevent if 
possible a return of the trouble, which is very apt to occur. Should bleeding 




Fig. 135. — Jarvis' Snare, Straight or Curved. 




arise, it may be checked by applying ice cold water or strong alum water. 
The removal of benign new growths other than polyps may be accomplished 
by means of the cold or hot snare, electrolysis, or the galvanocautery knife. 

Benign Tumors of the Larynx and Trachea 

The most frequent benign tumor of the larynx is the papilloma, which 
is found in children and adults. It is often multiple and may be located on 
the vocal cords or in the subglottic region. The prin- 
cipal symptoms are hoarseness, aphonia, and attacks 
of dyspncea. The diagnosis is established by the 
laryngoscope. The endolaryngeal treatment of pa- 
pillomata in children is not advisable according to 
the experience of the writer. Even after splitting the 
larynx and removing all growths, recurrence is fre- 
quent. All other tumors and cysts require surgical 
or endolaryngeal treatment. 

Fig. 136. -Congenital Malignant Growths 

Papilloma of Larynx. Thoge Qf ^ fonsi l s and so f t pa l ate are s l ow f 

growth, with involvement of the lymph nodes. Ma- 
lignant growths in the larynx, sarcoma and carcinoma, give the same symp- 
toms as benign growths in the beginning, but with every malignant ulcera- 
tive process we have in 
addition fcetid breath, 
bleeding, involvement of 
lymph nodes, and finally 
cachexia. To establish 
the diagnosis it is usually 
necessary to remove a 
piece of the swelling for 
microscopical examina- 
tion. However, mistakes 
are made with the micro- 
scope also, and whenthere 
is an element of doubt 
regarding the absence or 

presence of syphilis, an — Epithelioma of the Larynx (Shurly). 

inunction course should 
be instituted. With an 

early diagnosis radical means may be employed in good time (partial or 
total extirpation of the larynx) and life may be prolonged for two or three 




422 



THE RESPIRATORY SYSTEM 



years. The knife alone does not cure cancer, and the near future may 
give us a better insight into its pathology and better methods of cure. 

In sarcoma, injections of Coley's erysipelas toxines may be tried. 
Loeffler has recently suggested the antagonism of malaria and malignant 
new growths. The x rays and radium are also being employed in the treat- 
ment of "inoperable " malignant new growths. In doubtful cases anti- 
syphilitic treatment should be tried before operating or before giving an 
unfavorable prognosis. 

FOREIGN BODIES IN THE UPPER RESPIRATORY TRACT 

Foreign Bodies in the Nose. — In addition to rhinoliths {calculi in the 
nose), all kinds of foreign bodies have been found in the noses of children 
and demented persons. One sided suppuration of long duration is sugges- 
tive of a foreign body, which may 
remain impacted for years. The dis- 
charge in such cases is foetid and 
headache is a prominent symptom. 

Treatment. — After cleansing the 
nose, a strong light may be thrown 
into the nostril, and a careful search 
is then made by means of a probe. 
The removal of a foreign body is ac- 
complished by insufflation on the 
sound side with a Politzer air bag, or 
by means of a sharp curette or for- 
ceps, if necessary under narcosis. 

Foreign Bodies in the Pharynx. — 
Fishbones and needles may be seen 

Fig. 138.— Sarcoma of the Epiglottis in a g ood light, but are usually de- 

(Shurly). tected by a careful digital examina- 

tion and removed by means of a 
suitable forceps. Eating dry bread and swallowing a raw egg helps to dis- 
lodge a fishbone. Sometimes the foreign body has been expelled without 
the patient's knowledge, but no relief is felt, on account of the wound in 
the mucous membrane. 

Foreign Bodies in the Larynx. — The entrance of a foreign body into the 
larynx is attended with coughing and attacks of suffocation, and unless it is 
expelled inflammation and ulceration may supervene. 

Treatment. — When a foreign body is impacted above the vocal cords, 
it may be extracted with forceps. If it is below the vocal cords, the patient 
should be inverted, in which position gravity and a coughing spell may 
force out the foreign body. In case of a foreign body in the trachea, place 
the patient on a lounge in the abdominal posture, head downward, arms on 
the floor, and instruct him to take a slow, deep inspiration and follow it 
with a forcible cough. If this is unsuccessful, tracheotomy should be done, 
when the foreign body may possibly be reached with forceps. Foreign 
bodies have been located by means of the bronchoscope. 




HAEMORRHAGE AND NASAL DEFORMITIES 



423 



HEMORRHAGE FROM THE UPPER RESPIRATORY TRACT (EPISTAXIS) 

Haemorrhage from the nose may be due to traumatism, nasal disease, 
local erosions from picking with the fingers, racemose veins, or circulatory 
disturbances (hear disease). Persons with acquired or hereditary haemo- 
philia or other constitutional diseases (scurvy) are apt to bleed from the 
nose. The bleeding may be of a vicarious nature, as in young girls at 
the time of menstruation. Syphilitic or tuberculous ulcerations and granu- 
lations are prone to bleed. In most instances the bleeding point is found 
at the anterior cartilaginous part of the septum. 

Treatment. — The nose should be cleansed and the bleeding point cauter- 
ized with the galvanocautery or lunar caustic or some other caustic. Anti- 
pyrine in 10 per cent solution, suprarenal solution, or strong alum water 
is also efficacious. Should the bleeding interfere with the investigation, 
it is proper to plug the nostril and make a further search later. Anterior 
tamponade and postnasal tamponade are readily accomplished by means 
of punk, gauze, or absorbent cotton saturated with strong alum water or 
tannin and glycerine. The tampons should be removed on the second or 
third day and the tamponade renewed if necessary. The postnasal tam- 
ponade is accomplished by means of Bellocq's cannula or a flexible catheter. 

Laryngeal Haemorrhage. — A traumatic submucous haematoma may em- 
barrass respiration to such an extent as to require tracheotomy. Bleed- 
ing from the free mucous surface may occur in healthy persons or in persons 
suffering from a circulatory or constitutional disease. A careful examina- 
tion is necessary in order to ascertain the source of the haemorrhage, which 
usually subsides after the use of ice and suprarenal capsule internally and 
rest of the voice. Haemorrhage from the trachea may be due to severe 
constitutional disease, to erosions and ulcers of tuberculous or syphilitic 
origin, or to cancer. The treatment must be in harmony with the aetio- 
logical factors. 

DEFORMITIES 

Saddle Back Nose. — Deviations of the septum and spurs and enlarge- 
ment of the turbinated bodies are frequent causes of nasal obstruction. 
They may be bony, cartilaginous, or membranous, presenting symptoms 
almost identical with those of hypertrophic rhinitis. 

Treatment. — The treatment in such cases is strictly surgical, usually 
under cocaine (suprarenal) anaesthesia. Soft tissues may be removed by 
means of the knife or a cutting forceps (punch) . Bony tissue may be reduced 
by means of the hand saw or the electric drill. After septum operations 
splints are introduced to keep the septum straight until it is healed. Haemor- 
rhage may be controlled after the operation by introducing a firm pledget 
of cotton soaked in alum water or suprarenal decoction. 

After some operations on the septum we observe a permanent perfora- 
tion, which, however, is of no special importance. 

Saddle back nose, from whatever cause, such as syphilis, traumatism, 
tuberculosis, infectious abscesses, or lupus, may be corrected by the use 
of paraffin subcutaneously injected, and by other surgical means. Other 
deformities require surgical correction. 
28 



424 



THE RESPIRATORY SYSTEM 



DISEASE OF THE ACCESSORY SINUSES OF THE NOSE 

The frontal, ethmoidal, and maxillary sinuses are occasionally the seat 
of suppuration. The predisposing factors are syphilis, dental caries, 
traumatism, and an extension of acute rhinitis in infectious disease. The 
principal symptoms are headache, localized pain and sudden discharge, 
vertigo, and a pressure sensation. The most important symptom is the 
presence of pus in the nose, and it sometimes flows freely when the head 
is held in a certain position. Sensitiveness on pressure over a dus area is 
sometimes elicited, and transillumination by means of a strong electric 
light held in the mouth may show a dark area of pus. 

Treatment. — Frequent cleansing of the nose with warm salt water or 
any other mild disinfectant is often followed by a cure. The pus in such 
cases finds a vent through the natural openings into the nose. The maxillary 
sinus may also be tapped through the alveolar process (second molar or 
canine fossa). 

In ethmoidal disease any obstruction may be removed with the sharp 
curette or by ablation of the middle turbinated bone. The frontal sinus 
may be tapped through the bone between the eyebrows. 

The after-treatment consists in cleansing irrigations. 

Conservative treatment in cases of pus in the maxillary sinus in which 
a diseased tooth is not an serological factor is most desirable. The over- 
growth of tissue in the region of the ostium maxillare must be cut away 
to restore normal drainage. Should improvement fail to follow, the patient 
should be advised to live at the seashore or in the mountains. If we con- 
clude eventually that the mucous lining of the sinus has undergone degenera- 
tion, curetting of its walls through an artificial opening may be indicated. 

THE TONSIL IN ADULTS 

Simple or Catarrhal Amygdalitis has the same causes as catarrhal pharyn- 
gitis and is treated in the same way. 

Follicular or Lacunar Amygdalitis is generally an infection of the tonsil 
accompanied by a punctate exudation which is frequently of diphtheritic 
character. We are unable to distinguish one variety from the other except 
by a bacteriological test. Children have frequently contracted fatal diph- 
theria from adults supposed to be suffering with amygdalitis. 

The symptoms of amygdalitis are those of a general infection, fever, 
chill, headache, rapid pulse, even delirium, local pain and swelling, and 
indurated lymph nodes. 

Treatment. — A brisk cathartic, ice to suck, a moist dressing around the 
neck, gargling with chlorate of potassium (3j to Sviij) or ichthyol, 2 per 
cent, and the nasopharyngeal toilet. Scarification is permissible in the 
absence of diphtheria. 

Patients afflicted with acute amygdalitis should not mingle with children. 
In diphtheritic amygdalitis antitoxine is indicated (3,000 units). 

Phlegmonous Amygdalitis with Circumtonsillar Abscess 

Quinsy Sore Throat. — An infectious inflammation of the tonsil, circum- 
tonsillar tissue, usually one sided, with considerable local oedema and 



HYPERTROPHY OF THE TONSILS 



425 



swelling and inability to open the mouth and nasal regurgitation on swallow- 
ing, in addition to the general symptoms of infection. 

Treatment. — The treatment is that of follicular amygdalitis, and an 
incision into the tonsil or protruding and fluctuating soft palate is generally 
necessary. The mouth is gradually forced open, and with the aid of a good 
light the upper part of the tonsil near the edge of the palatine pillar or the 
palatine arch near the edge of the tonsil is cocainized and incised by plung- 
ing in a bistoury to the depth of half an inch. A guard of adhesive plaster 
wrapped around the knife blade half an inch from its point will prevent 
accidental injury of deeper parts. One or more incisions may be made, and 
a dressing forceps or blunt probe may be introduced into the abscess cavity 
to facilitate the flow of pus. 

Scarification and incision will do no harm even if pus is not found, and 
an abscess may subsequently find its way through the opening thus made. 
The after-treatment consists in 
gargling with hot antiseptic 
fluids. 

Tonsillar Concretions are oc- 
casionally met with, giving rise 
to local irritation. They may 
be detected by probing the 
crypts and may be removed by 
means of forceps after slitting 
open the ducts. 

Angina Ludovici (Phlegmon 
of the Neck). — A septic phleg- 
monous inflammation of the 
soft tissues of the neck and floor 
of the mouth, taking its origin 
in the buccal cavity or naso- 
pharynx and frequently proving 
fatal on account of laryngeal 
oedema and suffocation. In urgent cases tracheotomy is indicated and the 
usually deep seated abscess must be opened from the outside by a large 
incision and careful dissection. 

Hypertrophy of the Tonsils 

Faucial tonsil hypertrophy is more frequent in children than in adults. 

Symptoms. — Mouth breathing, snoring, nasal voice, etc. 

Treatment. — Removal by means of a Tiemann-Fahnenstock or Mc- 
Kenzie amygdalotome. (See Psediatric Section.) 

To prevent subsequent wound infection, the stump may be painted with 
a 25 per cent solution of chloral hydrate. In case of haemorrhage following 
amygdalotomy, the following treatment is to be employed: Gargling with 
alum water, swallowing ice, clamping and torsion of any bleeding vessel, 
the galvanocautery, manual and instrumental pressure, and ligation of the 
carotid. 




Fig. 139. — Peritonsillar Abscess. 
o, Point for incision. 



426 



THE RESPIRATORY SYSTEM 



The Use of the Tonsil Knife and Tonsillar Clipper 

Enlarged tonsils adherent to adjacent structures must be made free 
by means of the tonsil knife before they can be excised or they can be re- 
moved piecemeal by means of Gleitsmann's tonsillar clipper. 

Hypertrophy of the Lingual Tonsil at the base of the tongue is visible 
by means of the laryngeal mirror. It gives rise to cough, a foreign body 
sensation, haemorrhage, and pain. 

Treatment. — Removal with a snare or amygdalotome of special con- 
struction or by caustics. For the Pharyngeal Tonsil, see Adenoids. 

Mycosis of the Pharynx and Tonsils 

Leptothrix appears in small whitish nodules anywhere in the pharynx 
or on the tonsils, and seldom gives pronounced symptoms. 

The prognosis is good, but a prolonged and energetic treatment is re- 
quired for the eradication of the parasite. 

The plaques may be swabbed with tincture of iodine or nitrate of silver 
solution (10 per cent), or may be removed mechanically with the curette 
or galvanocautery or by excision of the tonsil. 

RESPIRATORY OBSTRUCTION 

(Edema of the Larynx or Glottis 

Stasis oedema may set in in nephritis, malarial disease, or heart disease, 
from pressure of a tumor, or from injury. Inflammatory oedema is ob- 
served in acute infectious diseases and local inflammations, and particularly 
in such processes as are localized in or near the larynx, such as diphtheria, 
deep abscesses, and erysipelas. The onset is much the same as in acute 
catarrhal laryngitis, with a gradually increasing impediment to respiration 
resulting in urgent dyspnoea and cyanosis. In the laryngoscopic mirror 
the epiglottis is seen to be bright red, semitransparent, and large. To the 
educated finger the epiglottis and the aryteenoepiglottic folds appear swollen 
and boggy. 

The prognosis depends upon the underlying cause and the adoption of 
proper means at the right time. If an ice bag, leeches, cathartics, and 
scarifications fail to give relief, tracheotomy must be done. 

Other causes of respiratory obstruction are foreign bodies, haemorrhage, 
croup membranes, aneurysm, mediastinal abscess, tumors and cysts, goitre 
and enlarged thymus gland, abscess {perichondritis), cicatrices, syphilis, spasm, 
and paralysis. 

A cheesy gland may rupture into the trachea and cause sudden death. 
Chronic obstruction may also result from faulty intubation with subsequent 
cicatricial stenosis of the larynx. Congenital syphilis may give rise to 
bronchostenosis in children. 

The principal symptom of respiratory obstruction is dyspnoea, and a 
careful anamnesis and local examination, including examination of the 
sputum, are necessary to diagnosticate the seat, extent, and cause of the 
respiratory obstruction. 



VASOMOTOR RHINITIS; HAY FEVER; POLLEN FEVER 



427 



Bronchostenosis may be suspected when there is impaired mobility 
followed by shrinking of the affected side. The vocal fremitus is lessened 
on the affected side, with a marked thrill of the thoracic wall. Percussion 
becomes less resonant and usually higher pitched over the affected lung, 
and dulness may be due to secondary atelectasis. Respiration is relatively 
feeble and vocal resonance is diminished on the affected side. There may 
be spasmodic cough, pleuritic pain, dyspnoea, and a mucopurulent discharge. 

Tracheal Stenosis may result from goitre, thoracic aneurysm, mediastinal 
tumor, new growths, or foreign bodies in the trachea. 

We observe long drawn, noisy respiration, slight motion of the trachea, 
and epigastric retraction. Vocal fremitus is diminished and pulmonary 
resonance usually clear. The patient complains of substernal pain and sore- 
ness or oppression. Dyspnoea is usually expiratory and constant, with 
exacerbations on exertion or at night and in the recumbent position. 
Laryngeal stenosis is excluded by visual examination. Cough and expecto- 
ration may be present. 

Treatment is either symptomatic, when the underlying condition is 
incurable, or specific in syphilitic affections, or surgical. The removal 
of impacted foreign bodies in a bronchus has been successfully accomplished 
in rare instances. In "inoperable " malignant new growths a daily ex- 
posure to the x rays for ten to fifteen minutes may be tried as a dernier 
ressort. 

NEUROSIS AND PARALYSIS OF THE UPPER RESPIRATORY TRACT 

Anosuria. — The loss of smell may be due to local disease or disease of 
the olfactory bulb or tract. 

The prognosis depends upon the underlying cause. It is unfavorable 
when the sense of smell has been extinct for several years. 

Treatment. — When anosuria exists because of nasal obstruction, owing 
to which odorous substances cannot reach the olfactory nerves, the removal 
of the obstruction is indicated. In central anosuria little can be accom- 
plished other than by hygienic management and antisyphilitic treatment 
when syphilis is the underlying cause. 

Reflex Neuroses. — Many reflex phenomena of nasal origin are observed 
in consequence of general and local reflex irritability or hyperesthesia. 
A careful examination in such cases will reveal some form of nasal obstruc- 
tion, but occasionally we meet with cases in which supersensitiveness 
exists in throat obstruction. Some of the reflex symptoms which take 
their origin in the nose are neuralgia or spasm about the head or face and 
redness at the tip of the nose (vasomotor disturbance, asthma, etc.). 

To determine that the reflex symptom arises from the nose, we try to 
elicit the reflex by probing or to remove it by cocainizing the nose. 

Treatment must be directed against the neurotic habit (cold sponge 
baths) and locally against all palpable lesions. 

Vasomotor Rhinitis; Hay Fever; Pollen Fever 

So called hay fever coryza, usually beginning in July and August, is 
distinguished from simple coryza by the incomplete intermissions between 



428 



THE RESPIRATORY SYSTEM 



the attacks and by the character of the secretion, which is watery and not 
purulent. In addition, the patient complains of general malaise, sneezing, 
and asthmatic attacks. 

Treatment should begin before the hay fever atta'ck sets in, by correcting 
any nasal obstruction which may be found. In the beginning of an attack 
the patient should take a stiff dose of quinine and calomel, and a few drops 
of a suprarenal solution containing 1 per cent of cocaine may be instilled 
into each nostril three or four times a day. The benzoinated albolene spray 
is also to be used and five grains of saccharated suprarenal powder may 
be taken internally three times a day. A change of climate is frequently 
beneficial. 

Professor Dunbar, of Hamburg, Germany, has succeeded in isolating 
the pollen poison from various grasses and has invented a hay fever serum 
(pollantin, Dunbar) which is to be applied locally in connection with the 
treatment outlined as above. It has given very satisfactory results in all 
forms of hay fever. 

Pollantin Dunbar is obtainable in the shops with full directions for 
its use. 

Neuroses of the Pharynx 

Gustatory Neuroses are rare. Loss of the sense of taste has been observed 
in hysteria, brain tumor, and local inflammations of the tongue and pharynx. 
Perverted taste is found in pregnancy and hysteria. 

The treatment is based on the underlying cause. 

Sensory Neurosis. — Hyper a:sthesia is found to be common in smokers 
and drinkers. It may be relieved by avoiding local irritation and by the 
internal administration of potassium bromide or the local application of 
cocaine to facilitate a laryngoscopic examination. 

Neuralgia of the Pharynx is rare. Paresthesia, abnormal sensation, is 
usually due to local causes in hypertrophic papillae at the base of the tongue 
in neurotic individuals. A painstaking examination often reveals the 
cause and indicates the treatment (cauterization and removal of hyper- 
trophic tissue, cold douches, and general hygienic measures). 

Motor Neurosis (spasms) are found in hydrophobia and in hysterical 
individuals. 

Paralysis is found in central disease, in diphtheria, and as the result of 
local causes. The prognosis and treatment depend upon the underlying 
cause. 

Neuroses oj the Larynx 

Laryngeal Anesthesia from central or peripheral causes and as a symp- 
tom in hysteria is dangerous because of the absence of all reflexes, so that 
food and drink pass into the larynx. 

Hyperesthesia is found in neurotics, in pregnant women, and in local 
inflammatory conditions. 

Paresthesia may have central or peripheral causes. 

The treatment of these conditions depends upon the underlying cause, 
and hydrotherapy is very useful in this class of cases, also electricity. The 
positive pole is applied over the larynx, and the negative pole intra- 
laryngeally. 



OFFICE FORMULA FOR NOSE AND THROAT TREATMENT 429 



Spasmus Glottidis is frequently observed in rhachitic infants, in pertussis, 
and as a reflex symptom in neurotic adults, also from pressure on the re- 
current nerve. It is occasionally fatal in young children, particularly 
when the attacks come on at every effort to swallow. The spasmodic 
attack in whooping cough may usually be cut short by manipulating the 
lower jaw as in ether asphyxia. In severe cases in children intubation is 
indicated, and the patient should have fresh air, proper food, and hydro- 
therapeutic management. 

Phonetic Spasm, a sudden complete or partial closure of the glottis 
with dyspnoea seen in hysteria and in professional speakers, requires hydro- 
therapeutic and tonic management. 

Vertigo of the Larynx begins with a tickling, burning sensation, followed 
by coughing, vertigo, and occasionally unconsciousness. It is observed 
in neurotic individuals, and cases are on record in which this symptom dis- 
appeared after the removal of a nasal polypus or elongated uvula or hyper- 
trophic lingual tonsil. 

The treatment therefore is local and constitutional (cold douche). 

Nervous Cough (reflex cough) and Trembling of the Vocal Cords are ob- 
served in neurotic individuals or as a reflex phenomenon from almost any 
organ of the body or from pressure of a tumor on the vagus. It is a hard, 
shrill cough with hardly any expectoration, and generally stops at night. 
If no underlying cause can be found, general hygienic measures, hydro- 
therapy, the bromides, and tonics, are indicated. 

Paralysis of the Muscles of the Larynx may be of central origin or due to 
injury, pressure, or infectious disease (diphtheria) acting upon the superior 
laryngeal nerve or to injury, pressure, or infection acting on the recurrent 
nerve and the vagus. Hysterical paralyses are common. In unilateral 
paralysis the unaffected cord may compensate in phonation by moving 
beyond the median line. The voice in such cases is weak and hoarse and 
sometimes changes to a falsetto. In bilateral paralysis aphonia is com- 
plete and the prognosis grave, as also in those cases in which the glottis is 
closed (bilateral abductor paralysis). 

Prognosis and Treatment. — The prognosis and treatment are based upon 
the serological factors. Central lesions, unless due to syphilis, give a bad 
prognosis. Pressure paralysis from cancer and aneurysm give an unfavor- 
able prognosis. Paralysis from "operable " goitre or enlarged glands may 
be cured. 

Hysterical paralysis requires moral, hygienic, and hydrotherapeutic 
treatment. In bilateral abductor paralysis intubation or tracheotomy is 
necessary to save life. 

OFFICE FORMULAE FOR NOSE AND THROAT TREATMENT 

Salt water, 3j to pint j, for spraying. 
Dobell's solution, for spraying. 
Listerine, diluted, for spraying. 

Cocaine solution, 2 per cent and 10 per cent, for local anaesthesia. 
Borax, 3ij, glycerine, 5ij, water, Bviij, for a spray in atrophic rhinitis. 
Alum solution, 5 per cent, to check haemorrhage. Apply on cotton 
as a tampon. 



430 THE RESPIRATORY SYSTEM 

Nitrate of silver solution, 2 per cent and 5 per cent. 
Trichloracetic acid in crystals, as a caustic. 
Chromic acid in crystals, as a caustic. 
Lactic acid, pure. 

Albolene, benzoinated or with menthol, as a spray. 
Orthoform powder for insufflation. 
Tincture of iodine for painting externally. 

Menthol, gr. v, camphor, gr. v, oleostearate of lime, Bj, for nasal dis- 
tress in colds. Use with a dropper. 
Adrenalin chloride solution. 

Adrenalin Solution: 

1$; Suprarenal powder, 

Water, 

Boil and filter. 
Add 

Formalin, 

Cocain., 

Formulae for Acute Rhinitis: 

R Acid carbolic, 

Alcohol, I __ 

Tincture of iodine, ( ' 
Aquae ammonia?, 

M. : Cork with cotton. Snuff the vapor in acute rhinitis. 



R Camphor, 5j; 

Menthol, gr. xv; 

Chloroform, 3ijss. 

M.: Gives relief in acute rhinitis. Inhale a few drops 
from a handkerchief. 

R Boric acid powder, 5ij; 

Menthol, gr. x. 



M. S.: Use as a snuff in acute rhinitis. 



3j; 
Bj; 

gtt. ij ; 
gr. x. 



for local anaesthesia and for 
reducing cedematous and 
hypersemic tissue. 



CHAPTER XVI 



THE RESPIRATORY SYSTEM — Concluded 

DEEP RESPIRATORY TRACT 

Synopsis: Clinical Features of Pulmonary Congestion, (Edema, Infarct, Abscess, Gangrene, 
Haemorrhage. — Acute Forms of Bronchitis and Pneumonia in Adults. — Chronic Forms of 
Bronchitis and Pneumonia. — Emphysema of the Lung. — Pneumoconiosis. — Bronchiec- 
tasis. — Cirrhosis of the Lung. — Tuberculosis of the Lung. — Bronchial Asthma. — Acute 
and Chronic Forms of Pleurisy. — Pleurisy with Effusion. — Hydrothorax, Haemotho- 
rax, Pyothorax, Pneumothorax. — Intrathoracic Tumors. — Affections of the Medias- 
tinum. 

CLINICAL FEATURES OF PULMONARY CONGESTION, (EDEMA, ETC. 

Pulmonary Congestion (Active, Passive, Hypostatic) 

Etiology. — Acute pulmonary congestion is regarded by some as a primary 
affection and by others as a symptomatic condition. Its aetiology is by 
no means clear in the present state of our knowledge. The causes and 
occurrences which lead to active hyperaemia are: Overaction of the heart, 
violent exertion, inhalation of irritants, extreme heat or cold, and alcoholic 
excess. It is frequently observed in epidemic influenza and in malarial 
disease, and all pulmonary disease is associated with congestion. 

Clinically it resembles the first stage of pneumonia, and for this reason 
many physicians are led to believe that pneumonia can be aborted. 

Symptoms and Physical Signs. — The onset is sudden, sometimes accom- 
panied by a chill. The temperature, respiration, and pulse rate are high. 
There is hardly any dulness on percussion. The breathing is broncho- 
vesicular, with fine rales. There may be cough, pain, and dyspnoea. The 
sputum may be frothy and bloody. 

Treatment. — Dry cupping and hot strong coffee may be administered. 
As a rule acute pulmonary congestion subsides in from twelve to twenty- 
four hours, with or without treatment. In urgent cases venesection is 
indicated. 

Passive Congestion may be mechanical, as in valvular heart disease 
and dilatation of the right ventricle, or from the pressure of a tumor. 

Symptoms. — The symptoms are dyspnoea, cough, and expectoration. 

Hypostatic Congestion is observed in low fevers (typhoid), adynamic 
states, and cerebral apoplexy and coma. 

Signs and Symptoms. — The signs and symptoms are not characteristic. 
There are dyspnoea, cough, frothy or bloody expectoration containing 

431 



432 



THE RESPIRATORY SYSTEM 



alveolar cells, a feeble pulse, usually no fever, slight dulness at the bases, 
feeble breathing sounds, and indistinct rales. It may be taken for pul- 
monary oedema, and vice versa. 

Treatment. — The treatment is that of the associated or underlying 
condition. Free bleeding may be necessary, and aspiration of the right 
auricle has been performed, but must be condemned as a reckless procedure. 
Camphor and caffeine may be given subcutaneously and the patient should 
have his position in bed changed from time to time. General mild massage 
may be employed for the purpose of improving the circulation. 

Pulmonary oedema is discussed in the chapter on Dropsy and Effusion. 

Pulmonary Infarction or Apoplexy 

Non-septic Infarction. — As a mechanical sequence of embolism and 
thrombosis of a pulmonary vessel, we occasionally observe a wedge-shaped 
hemorrhagic infarction in the lung representing an infusion of blood into the 
air cells and interstitial tissues. A non-septic infarction is not infrequently 
observed in chronic cardiac disease and may cause sudden death, when it 
is very extensive, by blockage of a large vessel. Small infarctions may 
give rise to no symptoms or may be suspected by reason of a sudden 
development of dyspnoea, pain, cough, and bloody expectoration in patients 
with cardiac lesions. 

Signs. — The physical signs in such cases are a circumscribed percussion 
dulness, increased vocal fremitus, pleural friction, and bronchial breathing, 
but without typical fever. 

Prognosis. — The prognosis in small non-septic infarction is not unfavor- 
able, and the treatment is entirely symptomatic, with due regard to the 
underlying cause. 

Septic infarction from a gangrenous or suppurating focus gives rise to 
about the same physical signs and symptoms as the non-septic form, but 
if the patient continues to live, the apoplectic area in the lung becomes 
gangrenous or there is abscess formation. 

The prognosis is naturally grave in such cases. The treatment is symp- 
tomatic. 

Abscess of the Lung 

Abscess may follow all forms of pneumonia or pulmonary tuberculosis, 
or may result from perforation of neighboring pus cavities, and from cancers, 
foreign bodies, or hydatid cysts. In all cases of pyaemia, embolic or meta- 
static abscesses may be found in the lung as in any other organ. 

Diagnosis. — The diagnosis is made by recognizing the physical signs of 
a cavity and by the character of the sputum, which has a peculiar offensive 
odor and often contains lung tissue and elastic fibres. 

Prognosis. — Abscesses following pneumonia may end in recovery. Ab- 
scesses in pysemic processes are usually fatal. 

Treatment. — The patient must be placed in the best possible hygienic 
surroundings and must be liberally fed on eggs, meat, cereals, fruit, cacao, 
etc. Medication is useless in the management of lung abscess. If the ab- 
scess is accessible, it should be opened and drained. 



HEMORRHAGE FROM THE LUNGS (HEMOPTYSIS) 



433 



Gangrene of the Lung 

This is due to necrosis and putrefactive changes of areas of lung tissue 
from all the various causes which are known to produce gangrene in other 
tissues. 

Symptom. — The distinguishing symptom is the very offensive odor of the 
patient's breath combined with evidences of sepsis, i. e., fever, rapid pulse, 
and prostration. Profuse haemorrhage from erosion of a large blood vessel 
may occur, and from the septic focus many distant complications may arise. 

Diagnosis. — The differential diagnosis between gangrene of the lung 
and putrid bronchitis may be difficult. An examination of the sputum 
in gangrene shows lung tissue, elastic fibres, ana bacteria. 

Prognosis. — The prognosis is grave. Limited gangrene may become 
encapsulated and finally heal. 

Treatment. — The treatment is unsatisfactory. The patient should 
breathe dust free air and receive the best of nourishing food and stimulation. 
The bowels should move freely once or twice a day. Inhalations of creosote, 
turpentine, or eucalyptol are employed. If localization of an encapsulated 
necrotic area is possible, we may resort to surgical means to give vent to 
septic material. 

Hemorrhage from the Lungs (H amoptysis) 

By haemoptysis we understand a coughing up of pure blood, not an 
expectoration of blood stained mucus. Fatal haemoptysis is rare and is 
due to rupture of an aneurysm or of a large sized vessel in the lung. 

Lesser haemorrhages are generally due to pulmonary tuberculosis, 
cardiac disease, disease of the blood vessels (syphilis, arteriosclerosis), 
haemophilia, sepsis, or vicarious menstruation. 

Symptoms. — Before a haemorrhage sets in there are sometimes premoni- 
tory symptoms, such as cough and soreness in the chest. As a rule haemop- 
tysis occurs without warning, except perhaps a tickling sensation followed 
by cough, after which blood is felt in the mouth. 

Source of the Haemorrhage. — When the physician is called to a patient 
bleeding from the mouth and coughing up blood, a careful examination 
as to the source of haemorrhage must be made at once, if possible. The 
bleeding may take its origin from the nose, pharynx, larynx, spongy gums, 
or the stomach. 

The characteristics of pulmonary bleeding are the cough, the bright red 
color of the frothy blood, and the bubbling rales in the chest. 

The patient is usually able to state whether the blood is coughed up or 
vomited. 

Treatment. — The patient must rest in bed for a few days and may wear 
an ice bag over the affected lung and over the heart. A fluid diet with 
cool drinks and ice is advisable, and opium may be given to relieve cough 
and allay excitement. If a direct cardiac sedative is called for, tincture 
of aconite may be given in drop doses. To increase the coagulability of 
the blood, gallic acid is recommended in five to ten grain doses, also 
acetate of lead (gr. ij) with opium (gr. \) every two hours. 

Clinical experience also favors the administration of ergotine by hypo- 



434 



THE RESPIRATORY SYSTEM 



dermic injection and antipyrine (five g ains every two hours) or suprarenal 
powder (five grains every two hours) . In a case of persistent and recurrent 
haemoptysis observed by the author, in a girl of sixteen, the bleeding was 
naturally and completely checked by the tampon action of a massive pleuritic 
serous exudate which formed on the affected side. 

According to the experience of many careful observers (Flint among 
others) pulmonary tuberculosis offers a more favorable prognosis as to duration 
of life when accompanied by bleeding than when this event is wanting. After 
the haemorrhage has completely ceased, the underlying cause should receive 
every attention. 



Acute and subacute bronchitis are catarrhal inflammations of the bron- 
chial mucosa probably due to microbial infection following a "cold " or ir- 
ritation from dust in the air, and are usually a downward extension of a 
nasopharyngeal catarrh or occur as symptoms or complications in influenza, 
asthma, tuberculosis, typhoid fever, cardiac and renal lesions, malarial 
disease, syphilis, rheumatism, gout, diabetes, and many other ailments. 

Symptoms. — The general symptoms are coryza, tickling in the throat, 
lassitude, creeping chills, and fever (101° to 103°) in severe or complicated 
cases. 

The cough is paroxysmal, rough, hard, sore, or dry at first, becoming 
loose in a few days. The patient complains of a sensation of tightness, 
compression, and rawness beneath the sternum, with pains in the chest, 
the back, and along the diaphragm, aggravated by coughing. 

Dyspnoea is marked only when the smaller tubes are involved, in infants 
and in the aged and feeble. 

Auscultation reveals harsh vesicular breathing; diffused, piping, sonorous 
or sibilant rales shifting and affected by the coughing, becoming mucous 
and bubbling; or subcrepitant rales if the finer bronchi are involved. 

Percussion gives clear resonance, unless there are complications, or ex- 
cessive resonance if there is an emphysematous condition of the lungs. 

Palpation reveals bronchial fremitus when the chest walls are thin and 
when there is much secretion. 

The sputum is clear, frothy at first, or mucopurulent, abundant in a 
few days, then purulent, with lumps of dried mucus, and is sometimes 
blood streaked. 

The voice is sometimes husky or suppressed. 

Prognosis. — The prognosis is favorable in mild cases, but grave in severe 
cases occurring in very young infants or in very old persons. 

Differential Points. — In sudden and severe cases, bronchitis may simulate 
lobar pneumonia in the first stage. Acute miliary tuberculosis may be 
mistaken for simple bronchitis. In both instances subsequent develop- 
ments will clear up the case. 

Treatment. — Rest in bed in febrile cases if the patient is in an enfeebled 
condition. He should have a hot soda foot bath and take in one dose: 



ACUTE FORMS OF BRONCHITIS IN ADULTS 



1^ Calomel, 
Jalap, 

Quinine sulph. 




gr. x (for an adult). 



ACUTE BRONCHITIS AND BRONCHOPNEUMONIA 



435 



He should also drink plenty of water, peppermint tea, or milk and Vichy 
water. 

When the cough is harassing, five to ten grains of Dover's powder or 
one tenth of a grain of heroin may be given once at night. Sea air and a 
change of air are very beneficial in the convalescent stage. The severe 
form requires powerful expectorants (see Bronchopneumonia). 

ACUTE BRONCHOPNEUMONIA (CATARRHAL PNEUMONIA; CAPILLARY 

BRONCHITIS) 

This disease is due to infection and inflammation of the small air cells 
by various cocci and bacilli. It may be primary, but is usually secondary to 
bronchitis, influenza, measles, pertussis, scarlatina, variola, etc. 

The disease may follow inspiration of food or drink, and is frequently 
observed after ether narcosis and in intubation cases or following operations 
on the mouth, nose, or trachea in children. Tuberculosis, malaria, rickets, 



Temp. 
Fab. 

105° 
















































































101° 






















































103° 










r 
















































102° 


















j\ in i : i 


Suit 


























Qr 












101° 






















































100' 






















































99° 






















































96° 


























































97" 

























































Fig. 140. — Effect of One Dose of Quinia in a Case of Malarial Bronchopneumonia. 

and diarrhceal diseases predispose to this infection. It is most frequent in 
aged persons and young children. The onset is usually gradual and insidious; 
it is commonly bilateral, but occasionally unilateral. It occurs in endemics 
as a "house infection" in overheated houses, school dormitories, soldiers' 
barracks, lumber camps, hospitals, asylums, prisons, etc., and is most 
prevalent in winter and spring. 

Bronchopneumonia may terminate in resolution in a few days (or after 
weeks by lysis), in suppuration, in gangrene, or in fibrous changes (chronic 
bronchopneumonia). When resolution is delayed, we should examine the 
sputum for tubercle bacilli. 

Inspection of a patient suffering from extensive bronchopneumonia re- 
veals rapid, shallow, and difficult breathing (60 to 80 a minute) ; an anxious, 
distressed countenance and dilating alse nasi; gradually increasing cyanosis 
with inspiratory retraction of the base of the sternum and of the lower 
costal cartilages. 

Physical Signs. — On percussion the chest resonance is at first not im- 
paired or may be somewhat tympanitic. After a day or two patches of 
impaired resonance can be made out. 



436 



THE RESPIRATORY SYSTEM 




7# < 



Auscultation reveals vesiculobronchial breathing with subcrepitant or 
mucous rales and rhonchi and occasionally patches of tubular breathing. 
These physical signs are apt to change from day to day as some areas clear 
up and others become involved in the inflammatory 
process. Pleuritic pain may be present. The cough 
may be violent and distressing. The sputum is muco- 
purulent and sometimes blood streaked. In general 
we observe rather the signs of bronchitis than those of 
pneumonia. In severe cases the pulse is rapid, the 
fever is high, the patient is restless or delirious or coma- 
tose, and convulsions may set in toward the fatal end. 

Prognosis. — The prognosis in feeble children and 
old people is grave. In older children and middle aged 
persons the prognosis in cases of ordinary severity is 
favorable. 

Differential Points. — In lobar pneumonia the onset 
is sudden, the inflammation is generally one sided, de- 
fervescence is critical, and the sputum is rusty. In 
tuberculous bronchopneumonia the physical signs may 
be identical with those of the ordinary variety, and a 
discrimination between the two forms may be impos- 
sible. In simple bronchitis there is less dyspnoea and 
distress and the rales are coarse and sibilant. 

Clinical Varieties. — In adults, as well as children, we 
see mild cases, severe cases, and grave septic cases with 
cerebral symptoms. 

Prophylaxis. — Bronchopneumonia patients should 
be isolated and the discharges disinfected. In all ca- 
tarrhal troubles the nasopharyngeal toilet should be 
practised and exposure to street dust and to bad air in 
crowded places should be avoided. 

Treatment. — An adult with bronchopneumonia 
should have a hot foot bath and go to bed. Fever 
diet and cooling drinks are indicated, also a brisk purge 
and 10 grains of quinine. High temperatures are con- 
trolled by hydrotherapy and early stimulation with 
whiskey, wine, enteroclysis, and such drugs as cam- 
phor and strychnine are indicated in septic cases. 
Cerebral symptoms require the application of an ice 
bag to the head. The trunk may be enveloped in a 
sheet wrung out in cold water, this to be changed 
every hour or two if necessary. When there is diffi- 
culty in raising the secretions, the foot of the bed may 
be raised from six to eight inches to allow them to 
gravitate outward. Carbonate of creosote may be 
given in 5 to 10 grain doses several times a day, but 
should be discontinued when the stomach becomes irritable. A change of 
position is also desirable. In the aged and feeble cold baths are not to be 
used. Sponge baths will answer very well, as the temperature is not very 



Fig. 141. — Diphthe- 
k i t i c Bronchial 
and Tracheal 
Cast(S. \Y. Kelley). 



ACUTE PULMONARY TUBERCULOSIS 



437 



high in old persons. Circulatory and respiratory stimulation is to be relied 
upon mainly, and digestion should be aided by giving hydrochloric acid 
after eating. (See General Therapeutics.) The management of broncho- 
pneumonia in children is discussed in the Paediatric portion of this work. 

ACUTE TUBERCULOUS BRONCHOPNEUMONIA (HASTY, OR GALLOPING, 

CONSUMPTION) 

Acute tuberculosis may result from direct infection or may be due to 
autoinfection from a preexisting tuberculous focus. All exhausting dis- 
eases predispose to it. It is met with in adults and in children, and not 
infrequently occurs after measles and pertussis or in young children, under 
the clinical picture of marasmus. 

Differential Points. — Acute pulmonary tuberculosis is liable to be mis- 
taken for some simple form of pneumonia, because the clinical symptoms 
and signs are very much alike and because the tubercle bacilli are not present 
in the sputum at first. When the tubercle bacilli are found, a simple form 
of pneumonia may be excluded. 

In typhoid fever with extensive bronchitis we observe rose spots, tym- 
panites, and the Widal reaction, without tubercle bacilli in the sputum. 

Clinical Forms of Acute Pulmonary Tuberculosis 

Pneumonic Form. — Abrupt onset with chill, remittent fever, frequent 
pulse, and hectic sweats; no leucocytosis. 

Dulness over one lobe (usually the upper) ; eventually cavernous or 
amphoric resonance. 

The sputum is scanty, mucoid, then rusty, mucopurulent, or purulent; 
tubercle bacilli; elastic tissue; perhaps haemoptysis. 

Duration, two to six weeks, occasionally two to four weeks. 

Bronchopneumonic Form. — High, irregular fever, frequent pulse, rapid 
emaciation; chills and profuse sweats or a typhoid state. 

Areas of impaired resonance, usually at the apex. 

The sputum is purulent, blood stained, nummular; elastic tissue and 
bacilli ; rarely haemoptysis. 

Not infrequent in young children after other acute infections. 
Duration, three weeks to three months. 

Miliary Form. — Repeated chills, fever (102° to 105°) ; very rapid, feeble, 
irregular pulse; profuse sweats; often vomiting at the onset. 

Hurried respiration (possibly 50 or 60 in adults) ; cyanosis generally 
marked; spleen frequently enlarged. 

Diffuse, sibilant or sonorous, mucous or crepitant rales; subpleural 
tubercle friction murmur, finer and softer than the pleuritic. 

Perhaps defective resonance at the bases in children. 

Dyspnoea very prominent from the outset without apparent cause. 

Sputum mucopurulent; occasionally rusty; may contain tubercle 
bacilli; rarely haemoptysis. 

Duration, two weeks to several months. 

Prognosis. — The prognosis of acute pulmonary tuberculosis is fatal. 
Treatment. — The treatment is symptomatic. 



438 



THE RESPIRATORY SYSTEM 



Acute fibrinous or diphtheritic bronchopneumonia is a rare disease ob- 
served in children as well as in adults. (See Fig. 141.) 

It may begin like a simple bronchitis or the onset may be severe with 
chills, fever, cough, and dyspnoea. When casts or membranes are expelled, 
there is a fall of temperature, which rises again if the casts form anew. In 
severe cases the patient dies of asphyxia and exhaustion in a few days. 
The mortality is 50 to 70 per cent. 

Treatment. — Diphtheria antitoxine, in 3,000 unit doses, should be re- 
peatedly given; saline inhalations, pilocarpine, gr. expectorants, and stim- 
ulants are indicated, also mercurial ointment inunctions. 

ACUTE LOBAR PNEUMONIA; FIBRINOUS PNEUMONITIS IN ADULTS 

Lobar pneumonia is an acute, infectious, endemic, and occasionally 
epidemic disease beginning with a chill. Probably several microorganisms 
are pathogenic factors in this disease, especially Friedliinder's pneumo- 
bacillus and A. Fraenkel's Diplococcus lanceolatus. The latter is of chief 
importance, since it is found in about 70 per cent of all cases of fibrinous 
pleuropneumonia. 

Fibrinous pneumonia has a catarrhal and a hemorrhagic stage. Both 
are usually included as the stage of congestion or engorgement. The lungs 
at this period show very little that is characteristic. They are dark red, 
still contain air, but are slightly firmer in consistence, and resemble mostly 
lungs affected with beginning hypostatic pneumonia. 

The hsemorrhagic stage is followed by the stage of red hepatization; the 
alveoli become filled with red blood corpuscles and fibrin. The latter 
coagulates, and the whole hsemorrhagic contents of the alveolus become a 
firm red plug. The cut surface of red hepatization is red and slightly 
granular. 

In the stage of resolution the fibrin undergoes granular disintegration 
and the cells undergo fatty metamorphosis. 

Fibrinous pneumonia generally attacks but one lobe, more frequently 
the lower lobe, and the right lung more often than the left. Sometimes 
both lungs and a number of lobes are attacked at the same time, but more 
often the invasion is successive, i. e., affection of one lobe is followed by 
involvement of another, until a whole side is hepatized. In these cases 
there is an intense collateral hyperaemia of the non-hepatized area, because 
the hepatized parts are always ansemic in the stage of complete hepatiza- 
tion. Acute vicarious emphysema (temporary emphysema) is also observed 
in the unaffected portions of the lung and presents an additional obstruction 
to the circulation in the right heart. The collateral fluxion very easily 
gives rise to a fatal pulmonary edema as soon as the heart begins to weaken 
as a result of the increased resistance and the injury caused by the high 
fever. 

Fibrinous pleuritis is a constant accompaniment of fibrinous pneumonia 
as soon as the latter appears in lobar form and involves the pleura. 

Every fibrinous pneumonia is attended by a violent bronchitis, acute 
catarrhal in the large bronchi and often fibrinous in the smaller, which may 
occasionally lead to filling and occlusion of the bronchi and bronchioli. 



ACUTE LOBAR PNEUMONIA IN ADULTS 



439 



In some cases fibrinous pleuropneumonia is accompanied by a purulent 
pleurisy in which the Diplococcus lanceolatus is usually found. Sometimes, 
especially in topers and when putrid processes have previously existed in 
the lungs, pneumonia goes on to gangrene. Rarely the fibrinous exudate 
becomes organized and replaced by connective tissue, so that the lung tissue 
becomes impermeable to air and assumes a fleshlike appearance (carnifi- 
cation) . 

Under certain conditions fibrinous pneumonia may terminate in caseous 
hepatization, especially when tuberculosis or caseous processes previously 
existed in the affected lung and when dissemination of tubercle bacilli can 
occur from these foci. 

Predisposing Factors. — Old age, overwork, debility, alcoholism, trauma, 
typhoid fever, measles, influenza, bronchitis, diabetes, tuberculosis, ether 
anaesthesia, chronic visceral disease, cold and damp weather, and previous 
attacks predispose. It occurs at all ages, and is more frequent in men. 
Pneumonia has a sudden onset (insidious in the aged) and ends by crisis in 
from five to nine days. 

Physical Signs. — Inspection reveals an anxious expression, bright eye, 
dilated alse nasi, labial herpes, pale face, or cyanosed with a mahogany 
flush on the checks; breathing hurried (30 to 60), but regular and noiseless, 
usually abdominal with deficient expansion on the affected side; posture 
often on this side; and the tongue dry and thickly coated. Early jaundice 
is common. 

Palpation shows lack of respiratory expansion over the area involved; 
vocal and tactile fremitus increased on the consolidated side (absent if 
pleurisy or bronchorrhcea is present or a main bronchus is occluded) ; and 
sometimes pleural friction fremitus. Tenderness on pressure is complained 
of also, and there is a dry, burning skin followed by profuse critical sweats. 
On percussion we find sharply defined woody dulness (rarely tympanitic over 
the upper lobe on the affected side). By the second or third day dulness 
is observed over consolidation (most marked posteriorly). High pitched 
tympany or the cracked pot sound is elicited in the stages of engorgement 
and resolution and above a hepatized area. 

On auscultation we hear inspiratory crepitant rales followed by typical 
bronchial breathing (provided the large bronchi are patulous), and later, in 
the stage of resolution, all sizes of moist rales; inspiration is short and 
suppressed, expiration grunting; bronchophony (most marked at the lower 
level of dulness) in the second stage; pectoriloquy or segophony above a 
hepatized area with exaggerated vesicular murmur in normal portions of 
the lung; and the second pulmonary sound accentuated in the sthenic type. 

The cough is short, dry, painful, and restrained at first; it may be absent 
in old people. 

The sputum is scanty, glairy, viscid, becoming blood tinged rusty sputum 
within twenty-four hours; more copious and liquid during resolution; 
purulent or like prune juice in low types; usually absent in children. The 
microscope shows pneumococci. 

The pain is unilateral, usually at the nipple or axilla, often agonizing 
and aggravated by cough or deep inspiration. Diffuse soreness is com- 
plained of. 

29 



440 



THE RESPIRATORY SYSTEM 



Respiration is panting and frequent, but there is really less dyspnoea 
than in bronchopneumonia. 

Generally speaking, there is an abrupt primary onset, with a distinct 
chill in adults and vomiting or convulsions in children; fever rises quickly 
to 104°-105°, falling by crisis in five to nine days ; the pulse is full and bound- 
ing (100-120), becoming weaker; the pulse respiration ratio is two to one or 
less; leucocytosis (absent in grave cases), severe headache, delirium (cere- 
bral symptoms may be marked in children and drunkards) ; chlorides in 
the urine are diminished or absent; the urine is high colored and perhaps 
contains a trace of albumin. 

Clinical Varieties. — In adults, as in children, we may recognize various 
clinical varieties of pneumonia — the septic and malignant types, epidemic 
pneumonia, influenza pneumonia, pneumonia of diabetics, pneumonia of 
alcoholics, pneumonia of old age (which comes on without a chill), migra- 
tory, or wandering, pneumonia, so called bilious pneumonia, when the 
patient is jaundiced, and typhoid pneumonia (which may mean a typhoid 
condition due to sepsis in pneumonia or pneumonia complicating typhoid 
fever). As regards localization, we may observe the apex, the lower lobe, 
or the middle lobe, on one or both sides, involved. 

A true double pneumonia is a very grave condition involving both sides. 

A massive pneumonia gives absolute flatness on percussion, as in wet 
pleurisy, owing to a filling of the bronchi with exudate. 

A central pneumonia is a deep seated localization of the inflammatory 
process in which we have all the clinical evidence of pneumonia, but fail 
to elicit dulness on percussion until the consolidation has reached the 
periphery of the lung. 

Differential Points. — In hypostatic congestion of the lungs the tempera- 
ture curve is not typical; dulness on percussion is often bilateral; typical 
bronchial breathing is absent. The sputum is not rusty. The distinguish- 
ing features in bronchopneumonia are discussed under Bronchopneumonia. 

In acute pulmonary oedema there is sudden cough, with intense dyspnoea 
and usually no fever; bronchial breathing is absent; the respiratory sounds 
are weak; subcrepitant rales are heard over both sides; the sputum is 
frothy and may be of a pale bright red, but is never "rusty." 

In pulmonary infarct, or apoplexy, we observe sudden dyspnoea and 
cough, a circumscribed area of dulness, little fever, and a very bloody 
sputum which is not "rusty." 

Acute pulmonary tuberculosis will extend over the ninth day, and tu- 
bercle bacilli will appear in the sputum. The temperature curve is not 
typical. 

In pleurisy with effusion the physical signs differ. There may be dis- 
tant bronchial breathing. The intercostal spaces bulge on deep inspiration; 
there is no sputum. The needle reveals fluid. 

Prognosis. — The prognosis is favorable in children and grave in adults. 
The disease is particularly fatal in drunkards and those afflicted with chronic 
disease. A pregnant woman who contracts pneumonia is dangerously ill 
and is apt to abort. Pneumonia is very fatal in plethoric and fat persons. 

Prophylaxis. — Pneumonia is most prevalent during cold and damp 
weather. Persons having a " cold " should not attend a theatre or church 



TREATMENT IN ACUTE LOBAR PNEUMONIA 



441 



or any function involving a large gathering of people. Living and sleeping 
apartments should be well ventilated and not heated above 68° to 70°. 
All sputum should be destroyed and the mouth and nasopharynx of the 
patient and attendants should be kept clean. 

Treatment. — Lobar pneumonia is a self-limited disease for which there 
is no specific curative treatment at the present time. The patient should 
have rest and breathe cold fresh air. When a person becomes ill with symp- 
toms of pneumonia he should take a hot foot bath and a brisk laxative. 

1$ Podophyllini, gr. ss; 



Calomel, 
Quinin. sulph., 




gr. x; 



Pulv. aromatic, g r -iij- 

M. S. : For one dose, in a wafer. 

This dose will bring away accumulations from the intestines and coun- 
teract any malarial factor. 

The patient remains in bed and is put on liquid or fever diet. Entero- 
clysis should be practised daily, and hydrochloric acid may be given to aid 
digestion. 

It is alleged that carbonate of creosote, in 5 to 10 grain doses every 
three hours, has a beneficial influence in pneumonia. The writer has not 
observed striking results from its administration in a number of cases. 

As circulatory failure in pneumonia is probably due to sepsis (toxaemia) 
and pulmonary obstruction combined with a strain upon the right heart. 
Early bleeding to the extent of §x to 5xv is indicated as soon as respiration 
becomes embarrassed and the veins are seen to fill up when a constriction 
is placed around the upper arm. 

After venesection drug stimulation may be tried as follows: 

Camphorse, | 
Pulv. digitalis, ) 
Acid benzoic, . . 
In a wafer: 

M. S. : One every four hours until eight are taken. 



gr- ij ; 
gr. v. 



Or we may give strychnine sulphate, gr. ^ to ^l, alternating with 
camphorated oil, gtt. x to xx, subcutaneously, or caffeine sodium benzoate, 
gr. ij to v, by the mouth or subcutaneously, or nitroglycerine, gr. T i ff , or 
ext. digitalis fluid., gtt. ij to v, subcutaneously. 

Generally speaking, drugs have very little influence in counteracting 
heart collapse. Whiskey is a food and stimulant, and can be given in 
large quantities if necessary, 5ij to oxvi in the course of a day. 

High Temperature with Delirium and Cerebral Symptoms. — To reduce 
very high fever, we employ hydrotherapeutics : Cool sponging, the cold 
pack, tub baths, 80° to 100°, warm mustard baths, 100°, or an ice cap to the 
head (see General Therapeutics). 

Local pain may be controlled by applying an ice bag or hot water bag 
to the seat of pain, or by cupping (dry or wet). Exceptionally a hypo- 



442 



THE RESPIRATORY SYSTEM 



dermic injection of morphine (gr. J) may be administered. Expectorants, 
such as liq. ammon. anisatus (gtt. ij to v) are indicated after resolution is 
evident. Cooling drinks, such as ginger ale and carbonated water, with and 
without champagne, are always indicated. The sputum and stools are to 
be disinfected and removed from the sick room as soon as possible. 

The diagnosis and management of complications such as pleurisy and 
empyema, endocarditis, meningitis, nephritis, parotitis, peritonitis, otitis, 
enterocolitis, embolism, etc., are discussed under their respective headings. 

CHRONIC FORMS OF BRONCHITIS AND BRONCHOPNEUMONIA 

Simple Chronic Bronchitis 

Simple chronic bronchitis may follow repeated attacks of acute bronchitis, 
and is commonly met with in chronic cardiac pulmonary and renal disease, 
also in arteriosclerosis and syphilis. It is the winter cough of old people 
and is frequently associated with emphysema of the lungs. 

Symptoms. — Shortness of breath on exertion. Freedom from cough in 
the summer, but a persistent cough in the winter, the chief distress being 
night and morning. The expectoration is mucopurulent or the cough may 
be dry. There is usually no fever, and the general health may be good with 
a tendency to emphysema and bronchiectasis. 

Physical Signs. — The chest is usually distended and the movements 
are limited, with diminished vocal fremitus in emphysema. 

Auscultation reveals expiration prolonged and feeble or wheezing, 
with diffuse, bilateral piping and snoring rhonchi or moist rales of all sizes 
(often crepitant at the base). 

Clinical Varieties. — In addition to the ordinary variety just described, 
we occasionally meet with cases of excessive bronchial secretion for which 
the term bronchorrhoea has been coined (purulenta and serosa). This variety 
is not to be confounded with bronchiectasis. 

Putrid bronchitis is met with in adults and children in connection with 
bronchiectasis, gangrene, abscess of the lung, or perforating empyema. 

Bronchitis with calcareous masses in the sputum is very rare. 

Dry catarrh with severe paroxysms of coughing without expectoration 
is often met with in older persons. In all cases of chronic bronchitis the 
sputum should be examined for tubercle bacilli. In all forms of chronic 
cough the sputum should be destroyed or disinfected, as it is a common 
experience to observe house injection with bronchitis and bronchopneumonia 
when such precautions are not taken. 

Chronic Fibrinous Bronchitis 

Fibrinous bronchitis is a rare disease. It occurs in both the acute and 
the chronic forms. 

Symptoms. — The symptoms in the chronic form are, as a rule, not urgent. 
The attacks usually follow upon long continued bronchial catarrh. The 
disease may last for years, the paroxysms recurring at regular or irregular 
intervals. Physical exploration of the chest during the attack often reveals 



CHRONIC BRONCHITIS 



443 



little that is distinctive. The respiratory murmur is usually more or less 
suppressed over the region of the occluded bronchi. Rales may be heard 
if there is accompanying bronchial catarrh. A napping sound, as in mem- 
branous croup, has been described in some cases when the casts have be- 
come loosened in the bronchi. After expulsion of the casts respiration may 
be heard in the parts of 
the lung before imper- 
vious to air. 

Diagnosis of Fibrinous 
Bronchitis. — F i b r i n o u s 
bronchitis can be diag- 
nosticated with certainty 
only when the character- 
istic arborescent casts are 
expectorated. 

Prognosis. — In the 
chronic form the prog- 
nosis is more favorable as 
regards life, but doubtful 
as regards complete re- 
storation. 

The treatment is that 
of chronic bronchitis. 

Treatment of Chronic 
Bronchitis. — The patient 
requires fresh air and a 
liberal diet. The bowels 
should move once a day, 
and five drops of dilute 
hydrochloric acid may be 
taken after meals, to aid 
digestion. Extremes of 
cold are to be avoided if 
possible, but the patient 
should sleep in a cold 

room with the windows open in a pure dust free atmosphere. General 
massage will exert a favorable influence on the circulation. Alcoholic 
stimulants and tobacco may be used moderately. 

The nose and throat should be kept moist by means of salt water and 
benzoinated albolene spray. 

Expectorants: Liquor ammonia? anisatus, five drops every four hours in 
sugar water. 




Fig. 142. 



-Fibrinous Cast or the Bronchi. 
Natural size. (Wood.) 



R^ Camphorse, 
Pulv. digitalis, 



aa, gr. ij ; 



Ext. hyoscyami, gr. 



In a wafer; one three times a day. 

R- Elixir of terebene hydrate with heroin, 
spoonful four times a day. 



A table- 



444 



THE RESPIRATORY SYSTEM 



Potass, iodid., 

Liq. ammon. anisat., . 
Tinct. opii camphorat 

Aquse, 

Syrupi tolutani, 



ojv. 



oij; 

5j; 

oij; 



oiij; 



M. S. : A tablespoonful four times a day. 



Emphysema oj the Lung 



Interstitial Emphysema results from violent expiratory efforts, as in 
whooping cough. A rupture of air vesicles takes place and air escapes 
into the interlobular connective tissue. In rare instances the air passes 
along the trachea into the subcutaneous tissue of the neck. This condition 
is not serious and requires no special treatment. 

Compensatory Emphysema of the lung is observed in pulmonary cir- 
rhosis, in pleural adhesions, or pleurisy with effusion, or in all conditions in 
which some portion of the lung is compressed or cannot expand and another 
portion of the lung must expand (become emphysematous) or the chest 
wall sink in. 

Hypertrophic substantive, or idiopathic, emphysema is a well marked 
clinical affection due to enlargement of the lung from a distention of air 
cells. It occurs in children and adults. 

Causes. — Chronic bronchitis; violent straining of the lungs as in whooping 
cough, asthma, heavy lifting, or glass blowing, or the work of blacksmiths 
and players on wind instruments; and narrowing of the air passages by 
new growths. Heredity predisposes. 

In all straining efforts and in cough the glottis is closed and the chest 
wall compressed by muscular effort. This high intraalveolar tension, 
acting upon a congenitally weak lung tissue, probably results in emphysema. 

General Characteristics of an Emphysematous Person. — A barrel-shaped 
chest; slow, abdominal respiration; forced expiration with bulging of the 
soft parts; inspiratory retraction of the soft parts; wide intercostal spaces; 
epigastric pulsation; dilated cervical veins; prominence of the accessory 
respiratory muscles; a swollen, cyanotic face; round shoulders; stooping 
posture; feeble pulse and apex beat; cardiac hypertrophy; gradual loss of 
flesh and strength; temperature usually subnormal; dropsy with dilated 
right ventricle; enlargement and displacement of the liver and spleen. 

Percussion reveals gradually extending, bilateral, drumlike, excessive 
resonance (reaches lower than normal) and the cardiac dulness commonly 
obliterated. 

Auscultation shows vocal resonance usually diminished; inspiration 
shortened; expiratory sound much prolonged, low, soft, and breezy (harsh 
and wheezy if there is asthma, with fine bubbling, mucous sibilant, and 
sonorous rales); perhaps crumpling sound like folding of parchment at the 
end of deep inspiration; second pulmonary sound accentuated; apex sounds 
diminished, often with a fine systolic murmur; and a crackling sound in 
the interstitial form. 

There is frequent cough, with a sense of constriction below the ribs, and 
even slight effort produces expiratory dyspncea with occasionally severe 



EMPHYSEMA AND PNEUMOCONIOSIS 



445 



asthmatic attacks. The sputum is frothy and viscid, but may be profuse 
and purulent if the trouble is associated with chronic bronchitis. The 
course of this disease is slow and progressive. 

Treatment. — The treatment is that of chronic bronchitis. In attacks 
of urgent dyspnoea and cyanosis venesection is indicated. General massage 
is beneficial. Strychnine may be administered internally. 

Atrophic Emphysema is a senile change with no enlargement of the 
thorax. 

Pneumoconiosis 

Pneumoconiosis is a chronic interstitial pneumonia due to the inhalation 
of dust incident to special employments. According to the cause, we recog- 
nize anthracosis (coal miner's disease), chalicosis (stone cutter's or grinder's 
disease), and siderosis (metal worker's disease), etc. In all such cases, a 
sputum examination will show the characteristic dust particles. 

General Characteristics. — Very gradual emaciation and loss of strength; 
slight continuous fever or none; pulse 100 or upward. 

The affected side is more or less immobile and shrunken; the intercostal 
spaces are obliterated; the heart is drawn over to the affected side; and there 
is spinal curvature with the shoulder drawn down. 

On palpation we note increased vocal fremitus over the affected area 
unless masked by retraction and pleuritic complications; the apex beat 
displaced toward the affected area. 

Percussion reveals perhaps persistent absolute dulness, with woody re- 
sistance at the base or apex; flat tympany or amphoric sound over a saccu- 
lated bronchus; excessive resonance on the sound side. 

Auscultation shows cavernous or amphoric breathing at the apex — blow- 
ing or feeble (even suppressed) — with bubbling rales at the base; usually 
bronchophony; a cardiac murmur late in disease. 

The cough is chronic and paroxysmal with very little pain. 

There is slight shortness of breath, especially on exertion. 

The sputum is mucopurulent and may be foetid, and later there is 
bleeding from the lung. 

Duration. — The disease is very chronic and may extend over ten to 
thirty years. Death results from intercurrent disease, haemoptysis, or 
cardiac or respiratory failure. 

Treatment. — The treatment is the same as for chronic bronchitis. If 
possible the patient should live an outdoor life in a mild climate. Hydro- 
chloric acid may be given to aid digestion, and heroin or morphine to over- 
come distressing cough in terminal stage. 

Pulmonary Actinomycosis is an invasion of the lung by the ray fungus 
(Streptothrix actinomyces). The symptoms are those of putrid bronchitis, 
pulmonary abscess, or chronic tuberculosis, with irregular fever and offensive 
sputum. An empyema may result. The organism is found in the sputum 
as sulphur colored granules. G. R. Butler, M. D., has reported a case 
terminating in recovery under the use of oil of eucalyptus (Medical News, 
April 29, 1898). 

Syphilis of the Lungs may simulate chronic phthisis. In a number of 
cases observed by the writer the symptoms were cough, fever, and frequent 



446 



THE RESPIRATORY SYSTEM 



small haemorrhages in patients with a clear history of syphilis. The sputum 
examination was negative as to tubercle bacilli. 

The treatment is that of chronic bronchitis, in connection with proper 
hygiene, a liberal diet, and an inunction course. 

BRONCHIECTASIS 

Cylindrical or sacculated dilatation of the bronchi occurs in connection 
with the following conditions: Chronic bronchitis, emphysema, phthisis, 
catarrhal and interstitial pneumonia, chronic pleurisy, congenital atelectasis, 
foreign bodies, in or external pressure on the air tubes. The weaken- 
ing of the bronchial walls is the most important factor in inducing bron- 
chiectasis. 

The symptoms are those of the original disease, and the condition is 
suspected only when the patient, during a severe paroxysm of coughing and 
in changing his position, raises a large quantity of mucopus having a peculiar, 
somewhat foetid odor. The secretion is a copious, gray brown fluid, muco- 
purulent, acid, or foetid (Dittrich's plugs), and separates into three layers 
— frothy, watery, and granular. 

The physical signs are not always typical. In typical cases there are 
local diminished vesicular murmur and diminished vocal resonance; cavern- 
ous or amphoric sounds in the affected area, with mucous rales after a 
coughing fit. If there is extensive sacculation, we observe a contracted 
side and cyanosis on exertion; also clubbed finger tips and incurved nails 
in advanced cases. Vocal fremitus is sometimes suppressed, but generally 
increased, and there may be rhonchal fremitus. The breathing may be 
cavernous, cracked pot, or amphoric, or a limited area of impaired resonance 
may be noticeable, due to an accumulation of secretions usually in the lower 
or middle part of one lung (the right as a rule). There may be moderate 
fever, night sweats, diarrhoea, emaciation, rarely haemoptysis, and meta- 
static abscesses in the brain and elsewhere. 

The treatment is that of chronic bronchitis. 

Cirrhosis of the Lung (Chronic Interstitial Pneumonia) 

Fibroid changes in the lung tissue are circumscribed (local or diffuse). 
In the vast majority of cases such changes are unilateral and the unaffected 
lung is emphysematous. The fibroid lung is airless and hard, the pulmonary 
artery shows atheromatous changes, and the heart is hypertrophied. 

Causes. — Cirrhosis of the lung may be a sequel of lobar pneumonia and 
bronchopneumonia, or it may result from chronic pleurisy and be a con- 
sequence of syphilis or pneumoconiosis. When it is of a tuberculous nature, 
we speak of fibroid phthisis, which is clinically identical with fibroid pneu- 
monia. 

Treatment. — The treatment is that of chronic bronchitis. 

CHRONIC PULMONARY TUBERCULOSIS; TUBERCULOUS BRONCHOPNEU- 
MONIA; CONSUMPTION; PHTHISIS 

Pulmonary tuberculosis is a communicable, preventable, and curable 
disease. As an early diagnosis is of great practicable importance, two stages 



CHRONIC PULMONARY TUBERCULOSIS 



447 



of the disease will be discussed: The incipient stage and the pronounced 
fee. 

The Incipient Stage. — Long before the localized physical signs of tuber- 
culous infection are plain, the disease may be suspected and diagnosticated 
by careful observation. 

Anamnesic Data. — Heredity, anaemia, bronchitis, pleurisy, syphilis, and 
all exhausting conditions, bad habits, dissipation, grief, worry, overwork, 
and insufficient nourishment are predisposing factors in tuberculous infec- 
tion. Pulmonary tuberculosis is most common in thin, tall people, with 
winged scapulae and long, narrow chests, flattened from front to back, and 
sloping ribs without sufficient respiratory capacity. 

Inquiry as to prolonged contact with a tuberculous patient or living in 
a notoriously infected sleeping room is of importance. In unmarried young 
women irregularity of menstruation has been noticed in the " pretuberculous 
stage." 

Symptoms. — The following general symptoms may be observed: Early 
slight fever in the afternoon or following exertion; later, continuous re- 
mittent or intermittent fever (temperature frequently subnormal in the 
morning); early anorexia; gradually increasing debility and loss of weight; 
pulse frequent and soft, but full; chloroansemia, including ar anaemic 
condition of the upper respiratory tract; early vasomotor disturbances 
(chilly sensations and flashes of heat), and often slight pleuritic pain. 

Pleuritic friction sounds may indicate infection of the pleura long before 
there is the slightest evidence of infection of the lung proper. Occasionally 
hoarseness or aphonia is the most prominent symptom which brings the 
patient to the physician. Gastrointestinal symptoms may be prominent 
and overshadow the pulmonary disease. In other instances bleeding from 
the lungs, when not of a vicarious nature, is the first prominent symptom; 
or a slight but persisting cough is complained of in addition to general 
lassitude, pallor, and loss of flesh. 

The physical signs are usually apical at first; early feeble (or harsh and 
rude), higher pitched breath sounds, with prolonged expiration; jerky or 
wavy cog wheel rhythm on deep inspiration; vesiculobronchial, then whif- 
fing and bronchial breathing with consolidation; localized subcrepitant, sibi- 
lant, and clicking rales, becoming bubbling and gurgling, blowing, or tu- 
bular (often heard distinctly if the patient coughs and then takes a deep 
inspiration) ; early impairment of resonance beneath and above one clav- 
icle. Fluoroscopy shows early diminution in apical transparency, enlarged 
bronchial glands, local opacity from pleural thickening, and restriction of 
diaphragm motions. Lymph nodes above the clavicle on the affected side 
may be palpable. 

In those instances in which the physical signs are quite negative, and 
we suspect incipient tuberculosis, a temperature record must be obtained, 
the temperature to be taken in the rectum twice daily for a period of weeks. 
A frequent or occasional elevation of temperature, in the absence of chronic 
malarial disease or other distinct causes, is strongly suggestive of incipient 
tuberculosis. 

In cases in which it is impossible to come to a satisfactory diagnosis of 
an abnormal condition, the tuberculin test is advisable. One minim of Koch's 



448 



THE RESPIRATORY SYSTEM 



tuberculin is mixed with one ounce of a half per cent carbolic acid solution. 
Ten drops of this solution represent one tenth of one milligramme of tuber- 
culin, and may be injected anywhere under the skin. In the absence of 
a decided rise of temperature, two, three, or five milligrammes may be 




Fig. 143. — Skiagram of Normal, Thorax. 



injected at one time. A decided rise of temperature following such injec- 
tions is highly suggestive of incipient tuberculosis. It is maintained by 
some observers that the tuberculin reaction can be obtained in a certain 
number of cases of syphilis. The author has no personal experience to 
report regarding this point. 

At the British Congress on Tuberculosis, in 1901, Robert Koch stated 
his belief that tuberculin injections were a valuable diagnostic means with- 
out danger. When the first injection gave a faint reaction, the second in- 
jection generally gave a marked reaction in tuberculosis. His observa- 
tions were based on 3,000 cases under his own control. 

Drs. Osier, Heron, McCall, Anderson, France, and Moeller thought that 
the use of tuberculin as a diagnostic test was valuable and safe. The author 
has used tuberculin as a test on many occasions and knows of no ill results 
except in one case, that of a child six years old afflicted with skin tubercu- 
losis. After an injection of one milligramme of tuberculin the normal tem- 
perature rose to 104° and three weeks later tuberculous meningitis set in 
which ended fatally. The autopsy showed a general miliary tuberculosis. 

For the detection of incipient tuberculosis an x ray examination appears 



CHRONIC PULMONARY TUBERCULOSIS 



449 



to be of some value. The patient is placed in front of and an inch from 
the tube. The fluoroscope is applied to the bare chest and passed up and 
down the thoracic region in search for tuberculous deposits or foci. A 
slight difference in the clearness of the apices may be left out of considera- 
tion, but a " spotted " lung is suspicious. 

In the present state of our knowledge and experience, the x ray view 
may be corroborative, but is not diagnostic of localized tuberculosis and is 
useless and misleading in the hands of an untrained physician. 

Pronounced and advanced cases of pulmonary tuberculosis are readily 
recognized by the finding of the tubercle bacilli in the sputum and by the 
physical signs in the chest. 

Examination. — Inspection and palpation show depression above or below 
one clavicle; often a wide area of cardiac impulse; short breathing, con- 
fined mainly to the lower third of the chest, with a retracted abdominal wall; 
quivering nostrils; a hectic flush, and general flushing on slight excitement; 
chloasma and pityriasis versicolor, a red line around the border of the gum; 




Fig. 144. — Skiagram. Right lung cavernous, left lung consolidated. 



multiple ulcers of the tongue; and clubbed finger ends with curved, cracked 
nails in very chronic cases. Local defective expansion is usually apical; 
tactile fremitus may be increased, particularly in the later stages, with 
cavity formation, unless the pleura is also much thickened; sometimes 
rhonchial fremitus; often soreness to the touch over the diseased parts; 



450 



THE RESPIRATORY SYSTEM 



swelling of the cervical lymph glands; and often dryness and harshness 
of the skin and hair. 

Percussion reveals dulness or flatness over a consolidation, which may 
be tympanitic or pseudocavernous where the consolidation is located around 
a bronchus or near the trachea. Percussion over large cavities gives the 
cracked pot sound, which is usually higher and louder when the mouth is 
open. Dulness and flatness are also elicited over cavities filled with fluid 
and over fibroid changes or dense pleuritic adhesions. 

Auscultation shows tubular breathing or cavernous or amphoric breathing 
sounds, rarely pectoriloquy over deposits and cavities; pleuritic friction 
sounds; often early diffuse cardiorespiratory whiffing (systolic bruit heard 
best during inspiration) ; commonly a pulmonary and subclavian systolic 
murmur; the second pulmonic sound accentuated; and the heart sounds 
heard posteriorly at the apex with undue distinctness. 

The early cough is dry and hacking (noticed on going to bed), or there 
is slight morning hawking and clearing of the throat, the cough becoming 
paroxysmal, looser, and more constant; distressing at night and on rising 
in the morning (from accumulated sputum) in the advanced stage; most 
marked when the patient is lying on the affected side in the early stage, 
on the sound side in the advanced stage. 

Pain, which may be sharp and is usually stabbing, felt near the nipple, 
or there may be a constant persistent, indistinct soreness and aching about 
the apex. 

Dyspnea is not usually prominent until the very advanced stage. 

The sputum is slight or absent at first; frothy, mucoid, and homogeneous 
(viscid and gelatinous if there is much pneumonic disturbance), becoming 
more copious, opaque, purulent, greenish yellow, often blood tinged, and 
with a sweetish odor. It is most abundant on rising. Haemoptysis is 
common and often occurs early. Cheesy particles containing tubercle 
bacilli, elastic tissue, cocci (mixed infection), and many red corpuscles are 
expectorated. 

The voice is hoarse or aphonic when the larynx is affected. 

In addition, there may be venous and capillary pulsation, drenching 
sweats at night or during sleep (most marked after cavity formation), 
late, obstinate diarrhoea, often albuminuria, a peculiar hopefulness, and 
rarely Curschmann's spirals in the sputum. Eosinophile cells in the sputum 
are of favorable import. 

Repeated detection of the tubercle bacilli in the sputum will enable us 
to distinguish between chronic bronchitis, bronchiectasis, and other forms of 
chronic cough and tuberculosis. A single finding of the bacilli is not 
conclusive, as they get into the sputum from breathing dust which con- 
tains them. 

Fibroid Phthisis. — One of the clinical varieties of pulmonary tuberculosis 
is the so called fibroid phthisis, which is clinically identical with chronic in- 
terstitial pneumonia and is distinguished by the finding of the tubercle 
bacilli in the sputum. The affected side is retracted and shrunken, the 
expansion poor, the percussion note dull, the breathing bronchial with 
rales. Patients may live many years with this form of tuberculosis. 



PROPHYLAXIS IN CHRONIC TUBERCULOSIS OF THE LUNG 451 




Fig. 145. 



Lesions in Chronic Tuberculosis of the Lung 

Miliary form, tuberculous bronchopneumonia, caseation and ulceration 
(cavities), fibroid changes, and pleurotuberculosis. 

Complications. — Laryngeal phthisis, pneumonia, pleurisy, with effusion 
or dry, interstitial tuberculosis, tuberculosis of the genitourinary tract, 
endocarditis, meningitis, aphonia and dyspha- 
gia, pneumop3 r othorax, fistula in ano, amyloid 
disease, neuritis. 

Prognosis. — In the early stages tuberculosis 
may be thrown off. In advanced cases the 
prognosis is unfavorable. Haemorrhages, un- 
less excessive, do not increase the gravity of the 
prognosis. When there is no hereditary ten- 
dency to tuberculosis, the prognosis as to ulti- 
mate cure is better than under other condi- 
tions. As regards duration of life, we must 
remember that the constitutional resistance 
varies with the individual, and constitutional 
resistance is an imponderable factor. 

The unfavorable symptoms are a rapid 
pulse, persistent slight fever, steady loss of 
weight, chronic diarrhoea, laryngeal tubercu- 
losis, etc. 

Death takes place in consequence of respir- 
atory failure, circulatory failure, haemorrhage, 
coma. 

Prophylaxis. — The battle against tuberculosis is a fight against social 
misery and against the tubercle bacillus. 

Private Prophylaxis. — The marriage of a consumptive should not be 
encouraged. A pregnant tuberculous woman should lead an outdoor life 

and make every effort to improve her condition 
in order that her offspring may benefit bodily 
and constitutionally. A new-born child should 
not be nourished at the breast of a tuberculous 
mother. A healthy wet nurse should be pro- 
vided or the child be fed on sterilized and modi- 
fied cow's milk. Kissing on the mouth is to be 
forbidden, and a tuberculous mother must not 
put spoons containing food for her children 
into her own mouth before feeding them. In 
every way possible consumptives must be kept 
away from children. The child should at an 
early age become accustomed to cold water 
sponging and be instructed in respiratory and 
general gymnastics. If the child is affected with 
tuberculous glands or adenoids, they should be removed. If possible, such 
children should be raised in the country or at the seashore, and every at- 



asphvxia, or cerebral 




Fig. 146. — Paper CrspiDOR. 



452 



THE RESPIRATORY SYSTEM 



tention must be given to the nourishment of the child. At the termination 
of the school period an outdoor occupation is to be selected. 

The following instructions may be given by the physician to the patient 
suffering from tuberculosis: The sputum is the main agent for the convey- 
ance of the virus, and it should 




be deposited in cheap muslin 
squares and burned, or in cuspi- 
dors containing an antiseptic 
substance (formalin, chlorinated 
lime). Overcrowding, defective 
ventilation, damp and dark 
dwellings, alcoholism, and syph- 
ilis are predisposing causes of 
disease, diminish the chances of 
cure, and are factors in reinfec- 
tion. Sunshine and fresh, dust 
free air (outdoor life) are the na- 
tural antidotes of the tubercle 
virus. Patients who live an in- 
door life and have an indoor 
occupation must give it up for 
an outdoor life and an outdoor 
occupation. There is no special 
climate for tuberculosis. 



Fig. 147.-Window Tent for Open Am Treat- Treatment. — The modern 

ment at Home. (Dr. s. A. Knopf.) management of pulmonary tu- 

berculosis comprises educational, 
prophylactic, hygienic, and dietetic measures, such as climatotherapy, aero- 
therapy, hydrotherapy, rest cure and exercise, dietetic management, and 
personal hygiene. 

Medication plays a minor role in the management of tuberculous patients. 
Treatment may be carried out at a private home in the city, in the country, 
or at the seashore, or at a sanatorium. The principles of treatment are 
best carried out by enlisting the cooperation of the patient. To this end a 
popular treatise on tuberculosis should be placed in the hands of the sufferer. 
The prize essay Tuberculosis, a Social Disease, by Dr. S. A. Knopf, of New 
York, is admirably adapted to this purpose on account of its clear cut 
portrait of the disease and its hopeful tone as regards curability. 

Climate. — Regarding climate, it may be stated that there is no particular 
or special climate which can be looked upon as a conditio sine qua non in the 
treatment of the infected individual. All things being equal, an outdoor 
life in a cold, dry, and clear air at a rather high altitude offers the best chances 
for a cure. For the guidance of those who are willing and able to travel, 
the following suggestions are offered: 

Marine Climate Dry Climate Mountain Climate 

Madeira. Egypt. . Colorado. 

Canary Islands. Mediterranean Basin. Montana. 



TREATMENT IN CHRONIC TUBERCULOSIS OF THE LUNG 453 



Marine Climate. 

Santa Barbara, Cal. 
West Indies. 
Florida. 

Sea voyages in the tem- 
perate zone. 



Dry Climate. 

Fort Bayard, New 
Mexico. 



Mountain Climate. 

Wyoming. 
Mexico. 
Adirondacks. 
Sullivan County, N. Y. 
North Carolina. 



Scrofulous children do well at the seashore; elderly people and those 
who take but little exercise or are afflicted with chronic cavities may go 
to a dry climate; younger persons with early consolidation improve in a 
mountain climate. 

Sanatorium treatment has great advantages as regards supervision of 
the patient and enforcement of the principles of the treatment. A residence 
of six months at a properly conducted sanatorium and a return to a clean 
house and a clean outdoor occupation will be of very great benefit to a 
large class of patients with incipient tuberculosis whose circumstances 
will not warrant a stay of from one to two years in an institution. Inas- 
much as the poor and ignorant class of people are the disseminators of 
tuberculosis, it is the duty of the 
State, from a humane and prophy- 
lactic point of view, to provide sana- 
toria at which the unfortunate could 
receive proper care and engage in 
some light occupation. The funds 
for such purposes should be raised by 
taxation. 

Home treatment is feasible in 
the city, in the country, or at the 
sea-shore. When a tuberculous indi- 
vidual is to be treated at his home, 
he should first of all be educated as 
outlined under Prophylactic Treat- 
ment, in order that he may not be a 
menace to his surroundings. A fever 
temperature and a pulse above 90 
make a rest cure desirable. In the 
city this would practically mean rest- 
ing in a reclining chair in a sunny 
room (or garden or roof tent) with 
the windows wide open day and night. 
Such a room should be absolutely 
bare of all but the necessary furni- 
ture. The walls and ceilings, if not 
of hard finish, should be kalsomined several times a year, or, if of hard 
finish, may be cleaned with cloths moistened in antiseptic solutions (for- 
malin) . 

The underwear should be thin wool, or linen, with warm stockings and 
sufficient outer garments to keep the patient comfortably warm. A warm 




Fig. 148. — Cut of Window Tent 
showing Ventilation. 



454 



THE RESPIRATORY SYSTEM 



cleansing bath is necessary twice a week, and a cold douche at 40° to 60° F. 
should be taken daily after breakfast. 

Diet. — The diet should be liberal as to variety and quantity. The fol- 
lowing specimen diet may serve to illustrate what is meant by a liberal 
diet: Meat, boiled fish, eggs, scraped meat, ham, tongue, oysters, herrings, 
caviar, sardelles, anchovies, cereals (all kinds), rice, bread, butter, potatoes, 
green salads, cooked vegetables, soup, milk, buttermilk, matzoon, honey, 
coffee, chocolate, cocoa, mint tea with tropon, puddings, Roman punch, 




Fig. 149. — Out Door Rest Cure. (Dr. S. A. Knopf.) 



ice cream, jellies, whiskey, kirsch, wine, extract of malt, beef jelly, cham- 
pagne, water, mineral water, and ginger ale. 

Fat has a high caloric value and is indicated in wasting diseases, in the 
shape of sweet butter or emulsion of cod liver oil. 

It is best to eat five times a day and not too much at a time. Five drops 
of dilute hydrochloric acid will aid digestion. The bowels must move at 
least once a day. 

The value of tent life in the country or at the seashore in the treatment 
of tuberculosis is now generally recognized. The results of tent life show 
that the appetite increases, nutrition improves, cough disappears, night 
sweats cease, sleep improves, weight increases, the temperature falls, the 
tendency to " take cold " diminishes, respiration improves, and the pulse 
rate diminishes. 

The construction of a proper tent or cabin for outdoor life can be 
studied from the cuts. 

Specific and Symptomatic Medication. — Koch's tuberculin is being used in 
yV to 1 milligramme doses in a number of sanatoria, and favorable results 
are reported by some and denied by others. The writer knows of two in- 
dividuals who became infected with tuberculosis and are cured after a course 
of tuberculin injections and two years of rigorous hygienic and dietetic 



TREATMENT IN CHRONIC TUBERCULOSIS OF THE LUNG 455 



management. On the other hand, one of his hospital patients, a girl of 
six years, afflicted with skin tuberculosis of the ulcerative type, was at- 
tacked with tuberculous meningitis four weeks after an injection of one 




456 



THE RESPIRATORY SYSTEM 



Creosote. — Clinical experience is somewhat favorable as regards the 
power of creosote to check to some extent the spread of tuberculosis in the 
tissues. The dose is from half a drop to six drops three times a day, in 
pill form, in milk, or with maltine. In some patients it distinctly upsets 
the stomach and its use is followed by a feeling of nausea and weakness. 
Under these circumstances its use should be discontinued. In the incipient 
stage hygiene, diet, hydrotherapy, and the x ray or sun baths should be 
employed to the exclusion of drugs. To aid digestion and thus prevent 
as much as possible intestinal putrefaction, we frequently administer 




Fig. 151. — The Tucker Tent. 
Plans for this tent can be obtained from Charity Organization Society, New York City. 

hydrochloric acid and tincture of mix vomica, five drops of each, in water, 
after a meal, or two drops of ichythol, in a capsule, twice a day, after eating. 

Cough. — A cough is Nature's effort to expel an irritant. This should 
be explained to the patient. Before resorting to medication to check a 
cough, the patient should be advised to use the nasopharyngeal toilet, and 
to endeavor to inhibit a dry cough by xvill poiver. When the cough is harass- 
ing, particularly at night, a dose of morphine (gr. \) or heroin (gr. T V) 
may be given; or the following combination: 



Py Acid hydrocyan. dil., gtt. xxiv; 

Potass, bromid., 5ij; 

Sol. morph. Magendie, 5jss. ; 

Chloral, hydrat., 3ij; 

Sp. frumenti, §j ; 

Syr. aurant., ad, gxij. 



M. S. : A tablespoonful when necessary to check cough. 

In urgent dyspnoea morphine injections and ozone inhalations give relief. 
Pain. — Pain in the chest may often be relieved by applying a hot water 
bag, a mustard plaster, or dry cups. 



BRONCHIAL ASTHMA 



457 



Hypcridrosis. — This may be relieved by having the patient rest over 
night in a coarse linen shirt or short night gown wrung out in cool water 
with sufficient blanket covering to avoid chilling. 

Fever. — In the management of fever, hydrotherapy should come before 
drugs. Sponging the body with cool water is preferable to tubbing. When 
the fever curve is suggestive of malaria, quinine is indicated; otherwise it 
has no beneficial effect and generally upsets the stomach. 

Insomnia is always an annoying feature in sickness. Before drugging 
the patient, it is well to try a cool sponge bath. Should this fail, a glass of 
strong beer or porter will sometimes produce sleep. In obstinate insomnia 
drugs must be employed, such as hydrate of chloral and potassium bromide, 
aa, gr. x to xx; (codeine, gr. \; urethane, gr. xxx); dionin, gr. \; trional, gr. 
xv, in milk; and hyoscine, gr. yott- 

The management of haemorrhage from the lungs and the treatment of 
genitourinary, intestinal, and laryngeal tuberculosis and other complications 
is discussed under separate headings, also that of the nervous and mental 
complications (neuritis, meningitis). 

Lung Surgery in the early period of cavity formation has a future, 
particularly when we have the facilities for opening the chest under suction, 
as with Sauerbruch's apparatus. 

BRONCHIAL ASTHMA 

Asthma is a term which has been generally applied to various conditions 
associated with dyspnoea. Thus, we speak of cardiac, renal, gastric, and 
thymic asthma. The term "asthma " should be employed only in connec- 
tion with bronchial asthma, which may be defined as a vasomotor tumes- 
cence of the bronchial mucosa, although the pathology of the disease is 
unsettled. The attacks are usually sudden, and probably take their origin 
in nasal, gastroenteric, renal, or genital reflexes or strong emotions. The 
disease is often associated with attacks known as "hay fever," or pollen 
fever. Most sufferers from " asthma " have a neurotic heredity. Bakers 
and workers in fur are afflicted more than any other class. Asthma is a dis- 
ease of adult life, but is not rare in childhood. 

"Symptoms. — When seen in an attack, the patient's face appears pale 
and cyanotic, staring and anxious, or dusky and covered with sweat during 
the paroxysms. The thorax looks enlarged, barrel-shaped, and fixed, and the 
diaphragm moves but slightly, with retraction of the intercostal spaces 
and epigastrium. 

Palpation sometimes reveals rhonchial fremitus, vocal fremitus dimin- 
ished or obscured, the apex beat diffused, and the heart laboring. The 
heart's impulse may be in the epigastrium. The surface of the body is 
cold and moist. 

Percussion shows marked excess of resonance, especially in chronic 
cases, extending over the cardiac space and low down to the eleventh rib. 

Auscultation reveals inspiration short and quick, expiration greatly 
prolonged, and low pitched wheezing in both acts. Innumerable faint or 
loud sibilant, and sonorous, musical, squeaking, and creaking rales, followed 
by moist cooing sounds, are heard, and the vesicular murmur is nearly 



458 



THE RESPIRATORY SYSTEM 



inaudible, or of the harsh, cog wheel type. The heart sounds are rapid and 
feeble. 

The cough is tight and dry at the beginning of paroxysms, becoming 
looser in time. Pain is usually initial, with a feeling of oppression about the 
chest. Dyspnoea is paroxysmal, periodical, expiratory, generally nocturnal, 
lasting from a few minutes to hours, and may recur during several nights. 
Expectoration is scanty, hard to expel at first, consisting of rounded gelat- 
inous pellets, Curschmann's spirals; often Charcot-Leyden crystals and 
eosinophiles, and rarely fibrinous casts. The voice is suppressed during a 
severe attack. 

There is no fever; the pulse is generally quick, small, and irregular during 
an attack. A sitting or standing posture is usually assumed by the patient. 
When bronchopneumonia sets in as a complication, there is a rise of tem- 
perature with a mucopurulent, sometimes blood streaked discharge. 

Acute emphysema of the lung is observed in severe attacks, and after fre- 
quent attacks of asthma, chronic emphysema and bronchitis with enlargement 
of the heart and congestive conditions in liver, lungs, and kidneys supervene. 

The course of the disease is variable. The paroxysms may recur for 
three or more nights and in the interval during the day there may be wheez- 
ing and cough. Death during the attack is almost unknown. 

Differential Points. — The dyspncea of hysteria and the "asthma" of 
renal and cardiac disease are not attended by the sonorous and piping rales 
and other physical signs of true asthma. A careful examination will also 
enable us to distinguish between true asthma and spasm of the glottis, ab- 
ductor paralysis, ozdema of the glottis, bronchial obstruction, etc. 

Treatment of an Acute Attack. — When we are called to a patient suffering 
from an acute asthmatic attack, prompt relief may be given to adults by 
means of morphine injected hypodermically (gr. \ to i) with or without 
atropine (gr. t^-q), or \ gr. each of morphine sulphate and cocaine hydro- 
chloride. Relief may also be obtained by taking a teaspoonful of the fol- 
lowing mixture every hour or two according to the severity of the case: 

No. 1 

Py Potass, iodid., 3ij; 

Liq. ammon. anisati, 5j; 

Tinct. opii camphorat., 5ij; 

Syr. tolut., 5jv; 

Aquae, ad, giij. 

M.: 

or No. 2 

R; Potass, iodid., 3 i j ; 

Morph. sulph., gr. j; 

Tinct. belladonnas, 

Liq. ammon. anisati, 

Syr. tolut., ad, Bij. 

M. S. : A teaspoonful in water every two or three hours. 

Potassium iodide may also be administered per rectum, dissolved in 
water (gr. xxx), and a dose of chloral (gr. x to xx) may be given by the 



aa, ojss. 



BRONCHIAL ASTHMA 



459 



mouth. The patient may smoke stramonium cigarettes or inhale the fumes 
of burning stramonium or nitre paper or asthma powder before drowsiness 
sets in and the patient forgets his misery in sleep. 

Powder for asthma, a teaspoonful to be burned under an improvised tent. 

Powd. saltpetre, 5j; 

Powd. stramonium, 5ij; 

Powd. lobelia, 5ij ; 

Powd. belladonna, 3ij; 

Powd. grindelia, 5ij; 

Powd. hydrastis canadensis, 3j- 

M.: 

When dyspnoea is urgent despite these measures, the inhalation of chlo- 
roform or chloroform internally often gives relief: 

1$ Chloroformi 5j; 

Morph. sulph., gr. j ; 

Pulv. gummi arabici, 3j; 

Syrup., 5jv; 

Aquse, ojv. 

M., ft. emulsio. S. : A teaspoonful every hour. 

In children the potassium iodide mixture No. 1 may be given in one half 
teaspoonful doses. Sulphate of atropine, gr. yio to gr. in adults, 
is used hypodermically to control the attacks. As soon as the acute 
attack is over, a careful and complete clinical examination must be made 
in order to ascertain if possible any underlying cause or source of irritation. 
The nasopharynx is a common irritation centre for asthmatic attacks. Nasal 
obstruction of whatsoever nature (hypertrophies, polyps, deviations, and 
spurs) must be removed (see Nasopharynx). Hypertrophic tonsils must 
be reduced and granulations in the pharynx are to be destroyed. After 
all this is accomplished, the nasopharynx may be kept clean and moist 
by means of a saline or albolene spray. Attacks of hay fever and sneezing 
are to be treated locally with cocaine and suprarenal decoction and with 
Dunbar's pollantin (see Hay Fever). The nasopharynx should be ex- 
amined several times a year for polyps, which are apt to recur. 

The digestive tract must receive every attention. The bowels should 
move once a day (abdominal massage, aloin pills, enemata). Five to ten 
drops of hydrochloric acid in water may be taken after each meal. Heavy 
meals are to be avoided because overloading the stomach may bring on an 
attack, but the diet may be liberal as to variety. Beans, peas, cabbage, 
pork, mayonnaise, and pastry are to be avoided, including such other 
articles of diet as are found to disagree. There is no special diet for asth- 
matics. Alcoholic stimulants may be taken in moderation. 

The Urogenital Tract in Asthma. — After a severe attack of asthma 
albumin is frequently found in the urine, but it usually disappears when the 
sufferer is comfortable and the circulation is not embarrassed. Excessive 
menstrual flow and endometritis may call for curettage. Frequent preg- 
nancies as a rule have an unfavorable influence on asthmatic women by 
favoring emphysematous changes in the lungs. 



460 



THE RESPIRATORY SYSTEM 



Neurotic Trouble. — The neurotic element in asthma must not be 
overlooked. Cold sponging or a rest cure with massage and passive exer- 
cise is helpful, and all fatiguing social duties are to be laid aside. Mental 
occupation is desirable for persons apt to become self-centred and morbid. 
Nearly all cases of asthma show evidences of a psychic element. 

Suggestion therapy is decidedly indicated in such cases, and occasionally 
hypnotism is of real benefit. Eye strain, when present, must be corrected. 
Hygiene of the skin in the shape of baths and friction must not be neglected. 
Very thin flannel or linen underwear should be worn all the year round, 
and in cold weather the outer garments should be heavy enough to protect 
against chill. The feet must be kept warm by means of thick stockings. 

Change of Climate for Asthmatics. — There are no fixed rules to 
guide us in suggesting a change of climate for asthmatics, but it is a positive 
fact that they enjoy a prolonged freedom from attacks in some places and 
not in others. Some of the writer's patients have done very well in Colorado, 
New Mexico, southern California, Florida, or the level of the sea at Nan- 
tucket and in other maritime districts. A trial sojourn is the only way 
to settle this question. Under no circumstances should asthmatics be in 
frequent contact with tuberculous subjects, on account of the special danger 
of becoming infected. As to the value of the pneumatic cabinet in the 
treatment of asthma, the writer can state that he has not observed favor- 
able results and does not advise such treatment. 

Bronchitis and bronchopneumonia are frequent sequelae of asthmatic 
attacks, and will require the treatment which is laid down for such con- 
ditions. Asthmatic patients frequently acquire chronic emphysema, which 
is practically incurable and requires symptomatic management. 

ACUTE AND CHRONIC PLEURISY 

General Remarks 

The pleural sacs extend from two to three inches below the lower border 
of the lungs. This so called complementary pleural space extends posteriorly 
from the ninth to the eleventh rib, and the surfaces of the reflected pleurae 
are in contact except when filled with fluid or separated by the border of 
the lung, which advances and retreats during respiration. 

Pleurisy, or inflammation of the pleura, is brought about by infection. 
Exposure and traumatism are predisposing factors. It may be primary 
or secondary, unilateral or bilateral. It is often associated with tuber- 
culosis, pneumonia, rheumatism, syphilis, pulmonary infarction, peri- 
carditis, typhoid fever, scarlatina, malarial disease, and other infections 
or with renal, hepatic, and cancerous disease and arteriosclerosis and gout. 

The three principal bacteriological forms of pleurisy are: The tuber- 
culous, the pneumococcic, and the streptococcic. 

The onset may be insidious or sudden. Clinically we distinguish the 
following forms: Dry pleurisy (acute or chronic, proliferative or calcified); 
effusive pleurisy (serous, hemorrhagic, purulent, chylous, encysted, inter- 
lobular, and pulsating) ; and diaphragmatic pleurisy (which may be dry or wet). 



DRY AND WET PLEURISY 



461 



Dry, Fibrinous, or Plastic Pleurisy 

occurs as an independent affection, with pain in the side, slight fever, 
and friction sounds as symptoms. There may be jerky, cog wheel, or sup- 
pressed breathing. As a secondary process, we find it in all inflammatory 
conditions of the lung, and we suspect its presence whenever a cough is 
very painful. In diaphragmatic pleurisy the pain is usually referred to the 
region of the liver or stomach, and the friction sounds are heard at the base. 

A dry pleurisy is often the first symptom of a tuberculous infection, 
with friction sounds at the base or apex. After persisting for a short time, 
the characteristic friction sounds disappear and no exudation takes place. 
Adhesions between the lung and costal pleura may take place, such ad- 
hesions giving rise to crackling friction sounds. 

The prognosis depends upon the underlying cause. A simple dry pleurisy 
admits of a favorable prognosis. 

Effusive Pleurisy, Wet Pleurisy 

This form of pleurisy may come on insidiously and is frequently over- 
looked. On examining a patient with moderate dyspnoea and accelerated 
pulse and normal or slightly elevated temperature, we are frequently sur- 
prised at finding the chest filled with fluid. 

Symptoms. — In other instances the patient complains of a chilly feeling 
for several days with an early sharp pain in the side. The pulse is quickened 
and the temperature may be 102° to 104°, its curve not being characteristic. 
Cough and expectoration may be absent. The breathing may be free or 
embarrassed. In some instances there are vomiting and delirium. There 
is no expectoration at first. In the event of an associated pulmonary 
inflammation, the sputum may be blood streaked or purulent if an empyema 
or purulent pleurisy has perforated into a bronchus. 

Physical Signs. — An effusion is recognized by the physical signs: Dulness 
on percussion, absence of vocal fremitus, and bulging of the intercostal 
spaces on deep inspiration. In many instances the physical signs are in- 
definite and a probatory puncture will be necessary to determine the presence 
or absence of fluid and its character. All these matters are discussed in 
detail in the section on Paediatrics. An effusion of more than 400 c.c. in 
adults or 120 c.c. in children may cause discomfort, but gives no very def- 
inite physical signs. When a puncture reveals fluid in the chest, it shows 
us at the same time its character and enables us to further look into the 
underlying pathological process by a laboratory examination of the fluid. 

Prognosis. — Acute non-purulent pleurisy may terminate as such in two 
or three weeks, with complete restitution to the normal, or may become 
more or less chronic and finally dry up, leaving dulness due to adhesions, 
or may turn into an empyema which requires an operation. 

In serofibrinous pleurisy the fluid is yellowish and clear or slightly 
turbid. It may be dark brown, particularly if the fluid is partly inspissated 
or has been in the pleural cavity a long time. It is rich in albumin and may 
coagulate spontaneously within and without the thorax. A coagulated 
exudate will not pass through an aspirating needle. Under the microscope 



462 



THE RESPIRATORY SYSTEM 



the cells pertaining to local inflammation are seen in the exudate. When 
the fluid in the right thorax is thick and dark brown, it may be of importance 
to look for liver cells. When the exudate is large, the lung is pushed into the 
apex, and apical dulness on percussion, with increased fremitus, will be 
evident. Large exudates displace adjacent organs, and on the right side 
depress the liver. 

Purulent pleurisy, or empyema, may begin abruptly or come on in- 
sidiously in the course of other disease, or it may be evolved from a serous 
pleurisy. Septic symptoms are rarely wanting in purulent pleurisy. For 
physical signs and termination, see the Pediatric Section of this book 

Hemorrhagic pleurisy is met with in malignant fevers, cancer, tuber- 
culosis, Bright's disease, and hepatic cirrhosis, and it may be produced ar- 
tificially by puncture for diagnostic or therapeutic purposes. It is occasion- 
ally difficult to distinguish this form from hemothorax which is the result 
of rupture of an aneurysm or pressure on the thoracic veins. A sanguineous 
exudate shows blood clot formation within and without the thorax. An 
aspirating needle entering a blood clot woidd not draw fluid. When a bloody 
fluid remains a long time in the thorax, the blood clot becomes disinte- 
grated and dissolved. A puncture made at such a time shows a fluid 
resembling blood which does not coagulate on standing. 

Diaphragmatic pleurisy may be dry or wet. In such cases the pain is 
low down, and the diaphragm appears to be fixed. Litten's diaphragm 
phenomenon is a " visible descending and ascending wave associated with 
the respiratory movements of the diaphragm in the lower zone of the tho- 
rax." It is of very little practical value in diagnosis. 

Encysted pleurisy is that condition in which adhesions separate the fluid 
into pockets, which may or may not communicate with one another. An 
interlobar encysted pleurisy is sometimes observed. 

Chylous pleurisy may result from injury to the thoracic duct, from a 
parasitic disease called filariasis, or from fatty metamorphosis of the epi- 
thelium. 

Pulsating pleurisy derives its name from the transmitted pulsations of 
blood vessels or the heart. 

Differential Diagnosis. — The important diagnostic points regarding 
pleural exudates, and particularly with reference to the conditions found 
in children, are discussed in Paediatrics, to which the reader is referred. 

Treatment of Dry Pleurisy. — A brisk purge should be given. 

Py Podophyllin., . 
Calomel, 
Quinin. sulph., 

M. S. : One dose. 

Quinine is given to counteract any malarial factor should it be present. 
Dry cups may be applied over the seat of pain, or a cold compress, an ice 
bag, or a hot water bag to the chest. Should this fail to give relief, ten 
grains of sodium salicylate and two grains of potassium iodide may be given 
every two to three hours, in lemonade. The pain may be so severe as to 
warrant a hypodermic injection of morphine (gr. \ to \) for an adult. 



gr- r, 

aa, gr. x. 

Take in wafer. 



TREATMENT IN PLEURISY 



463 



Treatment of Pleurisy with Effusion. — In the beginning the treatment 
is precisely as in dry pleurisy, but the patient should rest in bed and have 
liquid diet. When the temperature is high, hydrotherapeutic measures 
are indicated. As soon as effusion is evident, its nature may be ascertained, 
and if necessary a probatory puncture should be done, as there are no phys- 
ical signs which will enable us to distinguish between serous and purulent 
effusion. 

In the absence of severe and septic phenomena, we may assume that the 
fluid is not purulent, but the needle alone will prove the case. In the 
event of a purulent or seropurulent fluid, its immediate removal by incision 




Fig. 152. — Lung Gymnastics. 
Blowing a liquid from one bottle into another. 



and drainage is indicated. To facilitate drainage a portion of a rib should 
be resected. A serous fluid should not be removed immediately unless 
there is a vital indication for so doing. Very urgent dyspnoea which very 
greatly embarrasses the action of the heart, as in cases in which the fluid 
reaches to the clavicle, is one of the indications for removing by aspiration 
all or part of the fluid accumulation. The removal of a few ounces of fluid 
sometimes appears to start the absorption process. 

At this stage a somewhat dry diet is indicated, and a brisk purge every 
second day is beneficial. It is also advisable to act upon the skin and kid- 
neys by means of warm baths and enteroclysis at 110° F. Large exudates 
gradually disappear under such management. In some cases the wearing 



464 



THE RESPIRATORY SYSTEM 



of a moist compress around the chest, which may be wrung out in cold 
water and renewed once every two hours, gives great relief. The removal 
of fluid from the chest is readily accomplished in the manner indicated in 
the chapter on the Management of Dropsy and Effusion. 

After the removal of fluid the patient may practise respiratory gym- 
nastics in the open air or at an open window or blow water from one bottle 
into another in order to facilitate expansion of the lung. 

When fluid reaccumulates to its original height after puncture, it may 
be removed again. If only a small quantity of fluid reaccumulates, it may 
be left to Nature. In one of the writer's cases, a very massive pleuritic 
exudate completely tamponed or checked a recurring and alarming pul- 
monary haemorrhage in a girl of sixteen. The patient had repeated haemor- 
rhages during a period of two weeks, and nothing seemed to check the bleed- 
ing. In this case the fluid was purposely not removed; and at the present 
writing, ten years after the attack of haemoptysis, the affected chest appears 
quite free of disease. 

Chronic Pleurisy 

This may be dry or wet. In the dry form massive adhesions and prolifi- 
cation of connective or fibrous tissue sometimes take place, giving rise to 
dulness on percussion and marked vocal fremitus. In the chronic wet 
form adhesions and fibrous tissue formation take place and the retained 
fluid is confined in cystlike pockets. There is more or less flattening of the 
chest wall. In some instances the newly formed tissue becomes calcified, so 
that a needle introduced for diagnostic purposes will strike hard calcareous 
masses. The thickening of the membranes may compress and invade the 
lung and induce cirrhotic change. Probably many of the dry and chronic 
pleurisies are of tuberculous origin. 

Chronic pleurisy cannot be influenced by medication or surgery. The 
management is hygienic and symptomatic. When arteriosclerosis, chronic 
pleurisy, and cirrhosis of the kidneys are combined in one individual, the 
suffering by reason of urgent dyspncea is very great. Unilateral flushing 
of the face or dilatation of the pupil has been reported in dry chronic pleurisy 
as an evidence of irritation of the thoracic ganglion at the apex. 

HYDROTHORAX; HEMOTHORAX; PYOTHORAX; PNEUMOTHORAX 

Hydrothorax is a localized dropsy and as such a symptom of cardiac- 
renal, hsemic, hepatic, and other disease. It may be unilateral, but is gen- 
erally bilateral. It is distinguished from an effusion by the low specific 
gravity of the fluid (1.015) and its small percentage of albumin, and by 
the absence of the usual corpuscular elements of inflammation. It gives 
rise to the same physical signs and symptoms as pleural effusion, and may 
disappear spontaneously when the lagging circulation improves, particularly 
if we aid Nature by a judicious administration of diuretics, purgatives, and 
diaphoretics or revive an embarrassed heart by venesection. In urgent 
dyspncea relief may be afforded by the removal of some of the fluid. The 
modus operandi of thoracocentesis is discussed in the chapter on the Manage- 
ment of Dropsy and Effusions. 



HYDROTHORAX; HEMOTHORAX; PYOTHORAX; PNEUMOTHORAX 465 



Haemothorax may be due to trauma, leaking aneurysm, ulcerating 
blood vessels (phthisis), carcinoma, sarcoma, nephritis, scurvy, purpura, 
pernicious anaemia, leucaemia, or icterus. In marked cases with profuse 
haemorrhage we observe all the symptoms of shock — pallor and a feeble, 
rapid pulse. The physical signs are the same as in serous effusions. An 
aspiration into the dull area of the chest would reveal blood, provided the 
needle did not enter a blood clot. In haemothorax of long standing the blood 
clot is dissolved and the bloody fluid does not coagulate on standing. The 
treatment is symptomatic. 

Pyothorax is discussed in detail in the section on Paediatrics, under 
Empyema. 

Pneumothorax; Hydropneumo thorax ; Pyopneumothorax. Signs. — The 
physical signs vary according to whether there is open, closed, or valvular 
pneumothorax. 

Causes. — The usual causes are perforating chest wounds, neighboring 
malignant disease, rupture of air vesicles by strain, perforation due to local 
disease of lung, particularly tuberculosis, pleurobronchial fistula from 
empyema, and exploratory needle puncture. 

General Characteristics. — An anxious, alarmed expression; slight 
lividity; marked enlargement and immobility of the affected side; bulging 
of the intercostal spaces (unless offset by a cavity — flat chest) ; raised 
shoulder; marked displacement of the apex beat to the opposite side; the 
patient's usually lying on the affected side; and the respiration sixty or more 
a minute. 

Palpation reveals tactile fremitus greatly diminished or abolished, suc- 
cussion fremitus if fluid is present, and the liver sometimes greatly dis- 
placed downward. 

Differential Points. — In large pulmonary cavities the succussion 
and coin sounds are usually absent, there is no displacement of the heart, 
liver, or spleen, and there is depression rather than bulging of the inter- 
costal spaces. 

A distended stomach may cause tympanitic percussion with succussion 
and metallic tinkling, but a careful local examination together with the 
history will prevent confusion. 

Diaphragmatic hernia and subphrenic pyopneumothorax are possibilities 
to be thought of in obscure cases. 

Dulness over a pneumothorax may be mistaken for that of a pleuritic effusion, 
and a sonorous percussion sound in emphysema may suggest pneumothorax. 
In both instances succussion sounds, metallic tinkling, and coin sounds are 
absent. 

The percussion sound is amphoric or tympanitic or excessively resonant 
(rarely muffled, toneless, or almost dull when the tension is great) on most 
of the affected side, with movable dulness ; if fluid is present the sound side 
is overresonant. 

Auscultation shows the breath sounds greatly diminished or suppressed 
(sometimes amphoric if there is open perforation) on the affected side, 
exaggerated on opposite side, and feebly bronchial near the spine. There 
may be metallic tinkling on coughing or deep inspiration; a ringing amphoric 
voice (rarely feeble or absent if the opening is closed) ; whispering voice 



466 



THE RESPIRATORY SYSTEM 



transmitted; diathoracic coin sound very clear; a succussion splashing sound 
if liquid is present; and perhaps a metallic echo to the cardiac sounds. 
The coin sound is elicited by listening over the back and tapping one coin 
upon the other over the front of the chest. As air usually enters the pleural 
cavity during a paroxysm of cough, the pain is sudden and intense, dyspnoea 
is sudden and urgent, and there are general distress and restlessness with 
shock and a very rapid and feeble pulse. Exploratory puncture is negative 
in the air space. 

From an analysis of fifty-one cases observed in the Boston City Hospital 
in eighteen years Dr. J. L. Morse draws the following conclusions: 

Summary for Pneumothorax. — Pneumothorax is an uncommon con- 
dition. At least 70 per cent, and probably 85 per cent, of the cases of 
pneumothorax are tuberculous. The prognosis is good when it is due to 
trauma. It is fair when the pneumothorax is secondary to abscess of the 
lung. The results of excision of the ribs in these cases are very encourag- 
ing. Tuberculous pneumothorax is much more common in men than in 
women. It is most frequent in the third decade. It is about twice as 
frequent on the left as on the right side. The onset is acute in rather less 
than half the cases. Sudden pain and dyspnoea are the most common 
initial symptoms. The pneumothorax may be the first symptom of tuber- 
culosis noted. Displacement of the heart always occurs, being more marked 
in the left-sided cases. The pneumothorax is usually complicated by the 
presence of fluid, but may be simple. Air is rarely present alone in patients 
living more than a week. The fluid is more often purulent than serous. 
Recovery from the pneumothorax may occur in about 15 per cent of all 
cases. The cases which end in recovery are practically all serous. The 
patients usually die later, however, from pulmonary tuberculosis. The 
pneumothorax is the direct cause of death in 60 per cent. Eighty per cent 
of all the patients die in less than a year, and only 10 per cent live over 
five years. The prognosis is worse in right-sided than in left-sided and in 
purulent than in serous pneumothorax. It is worse in women than in men. 
Patients with pneumothorax are sometimes able to be up and about and 
even to do manual labor. 

Treatment. — The general treatment is symptomatic and directed to the 
underlying cause. Surgical intervention is to be considered in purulent 
cases and tapping in serous effusion. 

One of the most remarkable advances of recent date is represented by 
Sauerbruch's air chamber, which eliminates pneumothorax in intrathoracic 
operations. This is done by excluding the atmospheric pressure during 
the operative procedure, thus preventing collapsing of the lungs after being 
opened to the air. 



INTRATHORACIC TUMORS AND CYSTS (BENIGN TUMORS; DERMOID AND 
HYDATID CYSTS; MALIGNANT TUMORS) 

Benign tumors, such as fibromata, lipomata, chondromata, and osteomata, 
give no characteristic symptoms, and inasmuch as the thorax is not as yet 
a field for exploratory incision they present more of a pathological than 



INTRATHORACIC TUMORS AND CYSTS 



467 



clinical interest. In all obscure intrathoracic affections the possibility of a 
syphilitic lesion should not be overlooked and an antisyphilitic regimen 
adopted in all doubtful cases. 

Dermoid and hydatid cysts within the thorax are rarely encountered. 
They give rise to obscure pressure symptoms with local irritation. A 
diagnosis of such conditions might be arrived at by an examination of cyst 
contents obtained through puncture and aspiration. 

Malignant tumors of the lung and pleura are observed in middle and 
advanced life, rarely in children, and may be jointly discussed from a clinical 
standpoint. Cough and expectoration, pain, pressure symptoms, enlarged 
lymph nodes, and cachexia are the "group symptoms " of this class of 
lesions, and prolonged observation is often necessary to establish a diagnosis. 
An absolutely positive diagnosis of malignant tumor of the lung and pleura 
involves a microscopical demonstration of expectorated tumor elements. 

Carcinoma of the pleura gives the evidence of chronic pleurisy with and 
without effusion. Pain and cachexia are marked. Primary malignant 
new growths of the pleura are rare; they occur more frequently than other- 
wise in connection with carcinoma of adjoining viscera and mammary gland. 
Pleural exudates in connection with malignant growths are amber colored 
or sanguineous. When a pleural exudate is bloody and tuberculosis can 
be excluded, we have good grounds for suspecting a tumor in elderly in- 
dividuals. 

Malignant new growths in the lung are primary or secondary by con- 
tiguity and metastasis, and the associated lesions are enlargement of glands 
and pleural exudates. 

Symptoms. — Pain may be mild or severe. Fever may be absent. When 
it is present the temperature curve is not typical. Dyspnoea is an important 
and constant symptom, and may be paroxysmal. Cough, dry or moist, is 
present in most cases. The sputum may be mucous, purulent, sanguineous, 
prune juice colored, or foetid. A prune juice sputum by itself is not charac- 
teristic of cancer, but in conjunction with other symptoms it becomes 
significant. Pressure symptoms of some kind are invariably present. 
They include dysphagia (from pressure on the oesophagus), hoarseness 
and aphonia (from pressure on the recurrent laryngeal nerve), dyspnoea 
(from pressure on the trachea and bronchus) — an important and constant 
symptom which may be paroxysmal, and distention of veins and unilateral 
oedema of the face and neck. 

The rational physical signs are dulness or flatness on percussion and 
diminished vocal fremitus. On auscultation we notice friction sounds, 
weak breathing sounds, and rhonchi, unilateral or bilateral. 

Prognosis. — The disease ends fatally with an average duration of six 
to eight months. 

Differential Points between Aneurysm and Tumor. — In tumor we 
miss the tracheal tugging and the accentuated aortic second sound, and 
there is no difference in the radial pulse. A tumor may pulsate, but the 
expansile character of the pulsation is absent, as also the diastolic shock of 
the heart sounds. In malignant tumor there is much pain, the cervical 
and axillary glands are enlarged, and cachexia is marked. An x ray ex- 
amination will be helpful in the diagnosis of such conditions. To dis- 



468 



THE RESPIRATORY SYSTEM 



tinguish between tumor and encapsulated pleuritic effusion, an explora- 
tory puncture may be done. 

A chronic indurated fibrous condition of tuberculous or non-tuberculous 
or syphilitic origin may simulate tumor. A lengthy observation, during 
which time a mercurial inunction course may be carried out, will be necessary 
to come to a definite conclusion. 

Treatment. — In the present state of our knowledge we have no cure 
for malignant tumors which cannot be radically removed. In all cases the 
patient should have mercurial treatment. Exposure to x rays or radium 
may be tried as a therapeutic agent. When the dyspnoea is urgent, pleuritic 
effusion if present must be removed as often as necessary. Morphine relieves 
pain and dyspnoea. 

AFFECTIONS OF THE MEDIASTINUM 

Fibrous Mediastinitis. — The mediastinum may participate in the acute 
and chronic adhesive and proliferative inflammation of the pleura or peri- 
cardium, and at autopsies we occasionally recognize a fibrous mediastinitis 
or a gelatinous exudate. 

Emphysema of the mediastinum is associated with pneumothorax, or 
may be due to injury (tracheotomy with division of the deep fascia). 

Mediastinal lymphadenitis may result from all causes which may produce 
lymph node induration elsewhere. Suppurating glands may discharge 
into a bronchus or into the oesophagus or perforate into a large blood vessel. 

Mediastinal abscess occurs secondarily to spinal caries, syphilis, tuber- 
culosis, septic infection, traumatism, suppurating lymph nodes, etc. In 
addition to the general symptoms of sepsis (fever, chills, and sweats), there 
may be pressure symptoms, such as dysphagia, dyspnoea, a husky voice, 
aphonia, and a sense of weight or pain behind the sternum or between the 
shoulders. When a palpable swelling with superficial oedema is noticeable, 
an exploratory puncture is indicated. Most abscesses are situated in the 
anterior mediastinum, and when detected should be evacuated and drained. 

Enlarged Thymus Gland. — This condition is found occasionally in infants 
and may be suspected by reason of an abnormal substernal percussion 
dulness (see section on Pediatrics and diseases of the ductless glands). 

Mediastinal tumors are situated in the upper half of the chest. Wherever 
we elicit a substernal percussion dulness, and there are in addition pain, 
cough, and pressure symptoms, we shall have to distinguish between 
tumor, aneurysm, abscess, and a syphilitic gumma. 

The diastolic shock and expansile pulsation of aneurysm are absent in 
tumors. After excluding aneurysm, we give the patient the benefit of 
the doubt and direct an inunction course. Marked cachexia and an en- 
largement of glands speak for malignant tumors. Fever, chill, and sweats 
speak for pus. A systolic shock and pulsation may be transmitted to 
tumors and abscesses from underlying vessels. 

Treatment. — The treatment of all such conditions is symptomatic, 
except in syphilitic lesions, when it is specific with mercury and potassium 
iodide. Malignant tumors rarely have a duration of more than eighteen 
months. X ray treatment may be tried in such cases. 



CHAPTER XVII 



THE GENITOURINARY SYSTEM 

DISEASES OF THE GENITOURINARY ORGANS 

Synopsis: Remarks on the Clinical Pathology of the Urinary Tract. — Hematuria, Hemo- 
globinuria, Albuminuria, Pyuria. — Polyuria, Oliguria, Calculi, etc. — Remarks on 
Urination, Catheterism, Vesical Emergencies. — Remarks on Renal Insufficiency and 
Newer Methods of Diagnosis. — Diseases of the Kidneys. — Congestion, Acute and Chronic 
Nephritis. — Surgical Treatment of Nephritis. — Uremia and its Treatment. — Pyel- 
itis, Pyelonephritis, Pyonephrosis, Surgical Kidney. — Perinephritic Abscess. — Mov- 
able and Floating Kidney. — Diseases of the Ureters. — Ailments of the Bladder. — Extro- 
version, Diverticula. — Vesical Hypertrophy. — Vesical Neuroses and Paralyses. — Acute 
and Chronic Cystitis. — Ulcerative Cystitis, Pericystitis. — Stone in the Genitourinary 
Tract. — Syphilis of the Genitourinary Tract. — Tuberculosis of the Genitourinary 
Tract. — Benign and Malignant New Growths of the Genitourinary Tract. — Parasites 
of the Genitourinary Tract. — Localized and Minor Ailments of the Male Generative 
Organs. (Continued in following Section.) 

REMARKS ON THE CLINICAL PATHOLOGY OF THE GENITOURINARY 

TRACT 

The pathology of the genitourinary tract includes congenital defects, 
traumatism and its sequela?, infection, and parasitic invasion. The genito- 
urinary tract is frequently the seat of benign and malignant new growths 
or of concretions and foreign bodies. Kinking and compression of the 
ureters may give rise to retention phenomena, and the kidney may become 
loose in its attachment, and such displacement may be followed by various 
diseased conditions or reflex symptoms. Pregnancy occasionally gives rise 
to disturbances in the genitourinary tract, and functional derangements 
are very common. 

Infection of the genitourinary tract may occur in various ways. Micro- 
organisms in the circulation may pass out through the kidneys and leave 
them intact. Infection of one segment of the urinary organs may spread 
upward or downward to other segments and to adjoining tissues, as in 
tuberculosis and gonorrhoea of the genitourinary tract. 

Primary disease of a calyx may infect the bladder through the agency 
of the ureters and spread to the pelvic contents. Primary disease of the 
kidneys (tuberculosis) may infect all the lower urinary organs. Infection 
of the bladder may take place through the urethra, naturally or by catheter. 
Stagnation of urine, in consequence of stricture, paralysis, or a hypertrophic 
prostate, may result in back pressure and in ammoniacal fermentation with 
the production of sulphuretted hydrogen, which may become absorbed and 
act as a systemic poison or irritate the mucous membranes locally. Urinary 
concrements (stones) may form anywhere, composed of urates, uric acid, 

469 



470 



THE GENITOURINARY SYSTEM 



oxalate of calcium, or earthy salts joined by mucous or albuminous substances. 
Uric acid concrements are found in the kidney even in the new-born. The 
pathology of the uric acid diathesis will be discussed under Gout. Regard- 
ing oxalic concrements and those of cystine and xanthin we have no definite 
knowledge. Phosphatic concrements are apt to form when the urine becomes 
alkaline. 

Pain is a prominent symptom of most genitourinary troubles and when 
present is a valuable guide as to the locality of an ailment, particularly 
as to which side is affected. 

Waste products in the blood are eliminated in the urine, and all sub- 
stances which the kidneys secrete are in solution in the urine; therefore 
the condition of the urine depends largely upon the condition of the kidneys 
and of the blood flowing through them. The total solids in the urine vary 
from 3 to 12 per cent, and the quantity of urea secreted is in direct pro- 
portion to the quantity of blood passing through the kidneys and in con- 
formity with the food ingested. 

The quantity of water secreted is dependent on its supply and on the 
blood pressure and the state of the capillaries in the kidneys. Thus, in 
cardiac disease with simple albuminuria we can rely upon the diuretic action 
of digitalis so long as the kidney epithelia are not completely degenerated. All 
drugs which increase arterial pressure are diuretics, as also are a number 
of easily diffusible salts. 

Normal blood pressure with vasomotor dilatation of the kidney capil- 
laries is the probable explanation of polyuria. The relation of the heart 
and kidneys is very intimate. A weak left ventricle with low arterial 
pressure reduces the urine in quantity. Venous pressure in the kidney 
may become increased by inertia of the right ventricle or from local causes 
in the kidney itself. 

A general acute inflammation of the kidney or inertia of both sides of 
the heart, with low arterial and high venous pressure, as in heart disease, 
reduces the secretion of urine to a minimum. Finally, a decrease of urine 
is observed when there is vasomotor constriction in which the kidneys also 
participate, as in asphyxia, strychnine poisoning, and epileptic and eclamptic 
seizures. When the secreting epithelia suffer transitory or permanent 
changes, albumin shows in the urine. 

The urine is diminished (concentrated) when quantities of water leave 
the body by other routes, as in sweating, diarrhoea, etc., and the quantity 
of urine secreted will vary according to the degree of the change in one or 
both kidneys. The lumen of the uriniferous tubules is gradually diminished 
and obliterated by a local inflammatory process. When the resistance is 
equivalent to 60 mm. of mercury the secretion of urine ceases, but before 
this takes place the kidney becomes cedematous (hydronephrotic and 
finally atrophic). When the ureters are periodically occluded, the kidney 
parenchyma suffers but little, and large hydronephrotic sacs are formed 
by dilatation of the calices. Thus, clinically, we observe kidney lesions 
secondary to various diseases, also primary, such as acute and chronic 
parenchymatous degeneration by reason of infection and irritation. Ulti- 
mately complete atrophy and retraction occur, with total abeyance or 
loss of function. 



REMARKS ON ALBUMINURIA 



471 



The average daily amount of urine passed by an adult is from 33 to 40 
ounces, and in the case of a child, its age in years, doubled, will approxi- 
mately give the number of ounces per diem. The urine increases in quan- 
tity as the individual takes large quantities of fluids; it decreases on 
diminished consumption of fluids or loss of fluid by perspiration and 
diarrhoea. 

Polyuria is found in neurotic individuals and in true diabetes, also in 
chronic interstitial nephritis and in other conditions. The urine varies 
in color and has a specific gravity of about 1.020. The normal average daily 
quantity of urea excreted by an adult amounts to about 16 to 30 grammes 
(a little more than an ounce). A clear insight into the diseased con- 
ditions of a patient is impossible without a knowledge and examination of 
the urine. We investigate its specific gravity and look for albumin, sugar, 
bile, blood, pus, casts, etc. Hyaline casts may be found in almost any 
febrile condition and are not of grave import. In children, a severe nephritis 
with a smoky, bloody, and scanty urine showing albumin and blood casts 
may end in complete recovery if the heart remains intact. In gastro- 
enteritis of long standing albuminuria and nephritis are often found as a 
complication, also in malarial disease. In tuberculosis of the genitourinary 
tract the bacilli are not often found in the urine. Pus and blood in the urine 
may take their origin from any region of the genitourinary tract and from 
perforation of a neighboring abscess into the bladder. The urine of one 
kidney may be collected separately by means of a catheter passed into the 
ureter by the aid of the cystoscope. Retention and suppression of urine 
are readily distinguished. Incontinence, slow urination, and frequent 
urination may be of central or local origin. Convulsive substances (para- 
xanthin and acetone) are found in the urine after attacks of eclampsia. 
Urine may be preserved for a long time by adding to it a few drops of 
chloroform. 

Systemic Poisoning from Kidney Insufficiency 

The kidneys act as guardians and eliminators to the blood, and a dimi- 
nution of their function will result in an abnormal condition of the blood. 
Uraemia with somnolence, convulsive seizures, vomiting, blindness, paralysis, 
and disturbances of the heart and respiratory function, with or without 
fever, are due to kidney insufficiency. We look upon such phenomena as 
an evidence of systemic poisoning (for urea, uric acid, potassium salts, 
and kreatin are nerve poisons) , but we are unable to explain why in certain 
instances anuria of several days may persist without ura?mic symptoms. 
The diseased kidney itself throws poisonous substances (hypoxanthin and 
acetone) into the circulation, which thus irritate the vital and motor centres. 
Many experiments regarding the toxicity of urine have been made without 
any definite results. 

REMARKS ON ALBUMINURIA 

In the healthy individual the urine is supposed to be free of serum 
albumin and sugar. When large quantities of urine are manipulated and 
very delicate reagents are applied, both these substances are found in 
minute quantities. In some instances albumin is found occasionally in 
31 



472 



THE GENITOURINARY SYSTEM 



the urine of adults or children who are apparently in good health. The 
terms physiological, cyclical, accidental, and transient albuminuria have 
been coined for such cases. Albumin is found in the urine of individuals 
during or after great muscular fatigue, such as results from the forced 
marches of soldiers and in the case of athletes. Albumin is also found in 
the urine after eating eggs, etc. In such cases of transient albuminuria 
the afternoon urine is usually free. Anaemic children about the time of 
puberty may show transient albuminuria. As to the relative significance 
of nucleoalbumin and serum albumin, we have no definite knowledge. The 
important part is the relation of albuminuria to nephritis. The observations 
of G. M. Edebohls, of New York, who, in dislocated kidney with axis torsion 
of the ureter, has found albuminuria to disappear after fixation of the kidney, 
and who has recently advocated kidney decapsulation in otherwise incur- 
able cases of chronic Bright's disease, are of fundamental importance re- 
garding the clinical pathology of nephritis. At any rate it appears almost 
certain that there may exist albuminuria from local circulatory disturbances 
not connected with lesions of the kidney epithelia. 

Kidney epithelium is damaged in various ways: By microbial infection 
of all kinds, the action of toxines and metallic poisons, also cholaemia, 
closure of the renal artery, and circulatory disturbances in general. Clini- 
cally, it is well established that exposure to intense cold may be followed 
by inflammation of the kidney, but we do not understand thoroughly the 
causal nexus between skin and kidney lesions. 

In all of the instances cited above the albumin and globulin come from 
the blood (serum albumin). Those rare instances in which globulin is 
found alone (as in measles) are not cleared up. The intensity and extent 
of the epithelial degeneration are in many cases in direct proportion to 
the albumin found in the urine, but the quantity of urine excreted is no 
guide to the amount of albumin wasted. 

HEMATURIA 

In slight haematuria the microscope will detect the blood cells. In 
severe hsematuria the color of the urine is reddish brown or black, and the 
blood may clot. (See also Laboratory Aids to Diagnosis.) 

The causative factors are injury (stone, foreign bodies, instruments), 
congestion or inflammation anywhere in the genitourinary tract, in in- 
fectious diseases. Additional causes are haemophilia, purpura, scurvy, 
renal infarction, simple ulcer, carcinosis, tuberculosis, syphilis of the genito- 
urinary tract, ruptured veins, parasites, and poisoning by cantharides, 
turpentine, carbolic acid, potassium chlorate, etc. Idiopathic, or congenital, 
hereditary, and family haematuria has been reported. In order to make 
sure that the urine has not been contaminated by menstrual blood, it 
should be removed with a catheter. 

Regarding the source of the blood and the cause of the bleeding, much 
information may be elicited by a careful inquiry into the previous history 
of the patient. Thus, stone, tuberculosis, acute kidney infection, and 
sarcomatous degeneration are found in early life. Stone, stricture, cancer, 
and prostatic disease are more common in adults and in old people. 



HEMATURIA AND HEMOGLOBINURIA 



473 



In kidney tumors the kidney is enlarged and tender, the blood is inti- 
mately mixed with the urine, and rest has but little influence on the 
amount of blood. 

In stone in the kidney the general condition is usually good until a 
suppurative process is established in the kidney. The pain may be very 
severe, with a rise of temperature, simulating that of appendicitis when it 
is located on the right side. The bleeding is rarely profuse and is relieved 
by rest. The blood is intimately mixed with the urine. 

In tuberculosis of the kidney the blood is intimately mixed with the 
urine and the amount is slight. The pain is not of a colicky nature, the 
general health suffers, and pus is found in the urine at the same time, and 
also tubercle bacilli. 

Benign villous papillomata may provoke hsematuria. Such a condition 
can be recognized only by an exploratory operation. 

In tumor of the bladder the pain is not severe, the bleeding is intermittent, 
and the blood generally appears at the end of urination. 

In stone in the bladder, urination is frequent and arrested involuntarily; 
pain in the glans is complained of after urination and blood appears at 
the end of the act. 

In tuberculosis of the bladder the symptoms are those of cystitis. The 
pain usually ceases after urination. The blood is bright and appears 
suddenly. 

Prostatic disease sets in usually after middle age. The frequency of 
urination is increased without much pain. Blood may show at the begin- 
ning or end of urination. Attention has been called to hsematuria from 
healthy kidneys as the result of overexertion, in one case from horseback 
riding, in another from the bicycle. Such causes must be borne in mind. 
These forms of hsematuria are not attended with enlargement of the kidneys. 
They do, however, present sensitiveness on percussion, and the urine con- 
tains rouleaux of red blood corpuscles or bloody cylinders, but no casts. 
General symptoms of neurasthenia support the diagnosis. 

In doubtful cases an examination with the cystoscope, ureteral catheter, 
Harris's segregator, Luy's apparatus, or the x rays may be necessary for 
the diagnosis, or an exploratory incision may be justified. Regarding the 
use of the ureteral catheter, it may be said that the greatest care should 
be taken to avoid injury. 

HEMOGLOBINURIA 

Haemoglobinuria is that condition in which blood pigment appears in 
the urine. The paroxysmal form is characterized by chills and heat, various 
parsesthesias and pain, and a Burgundy red urine containing serum albumin, 
oxyhsemoglobin, methaemoglobin, and a few erythrocytes. Enlargement 
of liver and spleen, jaundice, and a feeling of anxiety are present. After 
an attack which may last for a few hours the stools are black. The causa- 
tion is unknown. Malaria, syphilis, and severe muscular exertion are looked 
upon as causes, also exposure to cold. Between attacks the patients are 
well, although some have albuminuria and in some cases attacks of albumi- 
nuria and haemoglobinuria alternate. The kidney epithelia may suffer 
from haemoglobinuria, and complete anuria result. 



474 



THE GENITOURINARY SYSTEM 



PYURIA; PUS IN THE URINE 

Pyuria is a very important symptom in disease of the urinary tract. 
It may occur from rupture of a neighboring pus deposit. When pus is 
found in the urine, the question arises as to its source. A large amount of 
pus usually comes from an inflamed bladder or from rupture of a pus sac 
into some part of the urinary canal. Urine with pus from the kidney is 
usually acid ; urine with pus from the bladder is usually alkaline. In pyuria 

due to disease of the urethra 
the urine first voided will 
contain pus, while the suc- 
ceeding portion is clear (two 
glass test). Pyuria due to 
disease of the ureters (tuber- 
culosis, stricture, calculus) 
may possibly be determined 
by ureteral catheterism or 
by means of the Harris seg- 
regator. 

The continuous or inter- 
mittent presence of pus in 
acid urine suggests tuber- 
culous, calculous, or obstruc- 
tive pyelitis, or surgical kid- 
ney. Ureteral catheterism, 
the Harris segregator, Luy's 
apparatus, or an explora- 
tory inspection of a painful 
and enlarged kidney may be 
necessary to determine the 
affected side. 

Outside sources of pus 
(pyosalpinx, suppurating 
pelvic cysts, and appendicu- 
lar abscess) are made out by bimanual palpation. A bacteriological ex- 
amination of the pus may reveal a number of specific microorganisms. 

POLYURIA, OLIGURIA, AND ANURIA 

Normal blood pressure with vasomotor dilatation of the blood vessels 
in the kidney is the probable explanation of polyuria, which is observed in 
chronic interstitial nephritis, in neurasthenia, in organic central nervous 
disease, during the absorption of large effusions, and in chronic diabetes. 
The term diabetes insipidus has been used in connection with polyuria. 
This term is misleading and apt to alarm the patient; consequently it should 
be abolished. 

Oliguria (diminished quantity of urine) is an evidence of low blood 
pressure. It is found in all severe fevers and in cases of weak heart, chronic 



Surg. 
Kid.<- 



Rerlal Calculus 




.'Hydatid Cyst 
iTuberc. Abs. 



Pyelitis 



Abs. of verm, append. 



Absc. above str. in 
ureter 



. -Abs. above stricture 
(] ' here 



. Site of rupt. o/ovar. 
cyst onperiton. surf. 



—Acetab. absc. 



-Trig, ulcer 
Suburetli absc. 
--■Skene's glands 

Fig. 153. — Sources of Pyuria. 
(Medical News, 1897.) 



REMARKS ON URINATION, CATHETERISM AND VESICAL EMERGENCIES 475 

parenchymatous nephritis, or great loss of the fluids of the body. Scanty 
urine, furthermore, occurs in occlusion of the ureter, in hysteria, and in 
lead intoxication. Anuria may be obstructive or non-obstructive (reflex). 

CALCULI 

Urinary concrements may form in any part of the urinary tract. They 
are composed of urates, uric acid, oxalate of calcium, or earthy salts held 
together by means of albuminous substances. Uric acid concrements are 
formed in the kidney even in infants. The pathology of the uric acid 
diathesis will be discussed under Gout. Regarding oxalic, cystine, and xan- 
thin concrements we have no definite knowledge. Phosphatic concrements 
are liable to form when the urine becomes alkaline. Pain is a prominent 
symptom of genitourinary troubles due to calculi. 

It is of great practical importance to know that chronic nephritis is 
often a unilateral disease, and that a typical renal colic may accompany an 
acute exacerbation of any inflammatory process in the kidney without the 
presence of renal calculi, a pain in such cases being probably due to distention 
of a resisting capsule. 

Mellituria, acetonuria, indicanuria, phosphaturia, lithuria, oxaluria, cys- 
tinuria, melanuria, mucous casts, microorganisms, and other pathological 
conditions of the urine, including the diazo reaction, are discussed under 
Uranalysis in the chapter on Laboratory Diagnosis. 

REMARKS ON URINATION, CATHETERISM, AND VESICAL EMERGENCIES 

Dysuria and strangury are terms used to designate spasmodic and pain- 
ful urination, and vesical tenesmus is often associated therewith. Irritating 
qualities of the urine, disorders of the bladder, the urethra, or the prostate 
gland, in women disease of the pelvic organs, and all inflammatory con- 
ditions of the lower intestine are the usual causative factors of dysuria. 

Difficult, slow, or interrupted urination is usually due to an obstruction 
in the urinary passages or to atony of the bladder and overdistention of 
this organ. Frequent micturition may be due to local irritation in the geni- 
tourinary tract, as to stone or to chronic cystitis, to undue local treat- 
ment or to a purely neurotic state, with or without local irritation. The 
frequent dribbling of urine due to overdistention is readily recognized by 
an unusually large bladder dulness on percussion. 

Incontinence is the inability to prevent the escape of urine, as in paralysis 
of the sphincter muscle of the bladder. It is one of the important symptoms 
in disease of the brain and spinal cord and in the so called typhoid state, 
but it is frequently a purely functional disturbance observed in neurotic 
individuals. An undue contraction of the detrusor muscles is also supposed 
to be the cause of incontinence. In fat women the mere act of coughing 
may produce incontinence, particularly when it is favored by mechanical 
conditions resulting from pelvic or perineal ailments. Some persons acquire 
the habit of urinating frequently because they have not far to go to the 
toilet room. 

Retention of urine may be due to brain and spinal cord disease, to the 



476 



THE GENITOURINARY SYSTEM 



typhoid state, to paralysis of the abdomen, as in peritonitis, to mechanical 
obstruction from an enlarged prostate or stone, or to simple hysteria 
Retention of urine is one of the important vesical emergencies which must 
be overcome by catheterism, and in the event of its failure, by suprapubic 
aspiration or by perineal incision. In catheterizing, the catheter and the 
hands of the operator must be thoroughly clean. The urethral orifice and 
its immediate neighborhood should be carefully wiped with a pledget of 
cotton saturated with a non-irritating antiseptic water (1 to 2,000 bichloride 
of mercury solution or a 2 per cent formalin solution). In catheterizing no 
force must be used, for fear of creating a false passage. 

The following kinds of catheters are in use: Soft gum catheters and silk 
woven gum elastic catheters, blunt and olivary pointed and flat. When 
an olivary catheter cannot be introduced, we may employ a whalebone 
filiform bougie, over which a Gouley tunneled catheter may be slipped. 
In some cases with prostatic hypertrophy we succeed best in entering the 
bladder by means of a Mercier catheter with a short beak. The ordinary 
silver catheter has a larger prostatic curve. 

Suppression of urine, or anuria, is a term used to designate the con- 
dition in which the urine does not reach the bladder. This can be estab- 
lished by catheterism. Total suppression is rarely observed; even in serious 
disease a small quantity of urine is usually secreted. It is found in disease 
of the kidney or in cases in which blood pressure is very much lowered or 
when the fluids of the body are lost in large quantities (choleraic diarrhoea). 
It is occasionally met with in neurotic women and children. There is also 
an obstructive suppression, in which case both ureters are occluded by an 
inside or outside obstruction, or the ureter of a healthy kidney may be 
kinked or obstructed and complete suppression result because of disease of 
the other kidney. 

REMARKS ON RENAL SUFFICIENCY AND NEWER AIDS TO DIAGNOSIS 

The condition of renal permeability remains the principal prognostic 
indicator, no matter what the anatomico clinical type of the renal lesion 
may be. We have various methods of estimating renal sufficiency: First, 
the estimation of the amount of urea secreted; second, the phloridzin test; 
third, cystoscopy and segregation of the urines; fourth, cryoscopy of the 
urine and blood. 

In renal insufficiency the excretion of urea is below the normal, and it 
is important therefore to know how much urea is secreted in twenty-four 
hours in a given case. The modus operandi of this test will be found in 
the chapter on Laboratory Examinations. The phloridzin test consists 
briefly in injecting sterilized phloridzi i subcutaneously, the urinary bladder 
having been previously emptied, and testing the urine for sugar half an 
hour after the injection; the test is again made at the end of the second 
half hour. Experiments have shown that the elimination is much greater 
in the normal than in the diseased kidney. Experiments made with urine 
taken from patients under ether have shown the renal function stimulated 
by the anaesthetic, if the kidneys are normal, but this is not true if the 
kidneys are diseased. 



CONGESTION OF THE KIDNEYS 



477 



CYSTOSCOPY, URETERAL CATHETERISM, AND CRYOSCOPY 

The cystoscope enables us to inspect the interior of the bladder and to 
insert a catheter into first one and then the other of the ureters, and thus 
draw off the urine from each kidney separately. 

Cryoscopy is, in brief, the determination of the freezing point of fluids 
containing substances in solution, and it is applied to the diagnosis and 
prognosis of cardiac and renal diseases. The freezing point of normal 
blood is 0.56° C. In renal insufficiency the freezing point is lower and 
falls with the accumulation of solid material in the blood. This test is 
made prior to a contemplated nephrectomy. A freezing point of . 58° C. 
does not contraindicate an operation. A freezing point of . 59° C. demands 
caution. A freezing point of 0.60° C. is a positive contraindication to any 
operative interference on the kidney, according to Dr. Kiimmel, of Hamburg, 
who has applied this test in 265 cases. The modus operandi of cryoscopy 
is described in the section on Clinical Laboratory Work. 

All these tests should be regarded as aids to diagnosis, and they are not 
to take the place of other well established clinical methods. Cystoscopy 
is not difficult to practise, but cannot be learned from a book. 

DISEASES OF THE KIDNEYS 

GENERAL REMARKS ON DIAGNOSIS 

The kidneys lie against the posterior abdominal wall, one on each side 
of the spinal column. The upper end of one is in contact with the liver 
and that of the other with the spleen. 

Bimanual palpation of the lower border of the normal kidney is possible 
in a subject with a lax and thin abdomen, in the recumbent or standing 
position. Abnormal mobility, enlargement, and tenderness are readily 
detected if they are present. Percussion gives uncertain results. 

When a diagnosis cannot be made by bimanual palpation and uran- 
alysis, with due consideration of the symptoms, we may employ the aspirat- 
ing needle or make an x ray examination. It is also possible to gather 
urine from each kidney separately by means of the Harris segregator and 
ureter catheterism, and in very obscure cases an exploratory incision is 
justifiable, particularly when one kidney is to be removed and we wish to 
be sure regarding the functional condition of the other kidney. In catheter- 
ism of the ureters the possibility of infecting or injuring those tubes is 
always to be borne in mind. An exploratory incision may be a safer pro- 
cedure than ureteral catheterism. 

For a careful analysis the entire amount of urine passed in twenty-four 
hours is necessary. The urine of infants may be collected by means of a 
wide mouthed bottle strapped over the genitals. To prevent contamination 
by vulvovaginal discharges, the urine may be taken by catheter. 

CONGESTION OF THE KIDNEYS; HYPEREMIA OF THE KIDNEYS; 
RUPTURE OF KIDNEY 

The disease may be acute, as in the early stages of acute infectious disease. 
The passive, or mechanical, congestion is usually due to cardiac, pulmonary, 



478 



THE GENITOURINARY SYSTEM 



or hepatic ailments and obstruction, or it may be due to the pressure of 
ascites, that of tumors, or that of the gravid uterus. Malposition and dis- 
placement of the kidneys may account for their congested condition. 

Symptoms. — The symptoms of kidney stasis are indefinite; the urine in 
such cases contains albumin and hyaline casts. 

Treatment. — When kidney congestion is suspected, the patient should 
have a full dose of calomel or blue mass (5 to 10 grains), followed by a saline 
cathartic. Enteroclysis and warm baths should be ordered. The diet 
should be restricted in conformity with the diet rules for the underlying 
diseases. 

Subcutaneous rupture o} the kidney from traumatism may be managed 
by rest and expectant treatment or by operative measures according to the 
nature of the case. 

REMARKS ON ACUTE AND CHRONIC NEPHRITIS (BRIGHT'S DISEASE) 

Inflammation and degeneration of the kidney structure are brought 
about by traumatism and infection, toxic irritation, and arteriosclerotic 
changes. Chronic gastrointestinal indigestion, chronic malarial disease, 
syphilis, and chronic alcoholism will affect the kidneys in the same way 
as they affect other glandular organs. The injury to the kidney may be 
of a temporary nature and pass off completely ; in such instance we speak 
of acute nephritis. When the kidney is permanently damaged, there is 
chronic nephritis, which ends in complete insufficiency of this organ. 
At the bedside we recognize an acute and a chronic Bright's disease, and 
clinically we may make a distinction between chronic parenchymatous 
and chronic interstitial nephritis (cirrhosis). All other distinctions, that 
of the amyloid kidney, for instance, are of pathological import only, and 
should be relegated to the dead house. 

ACUTE NEPHRITIS 

Acute Bright's disease occurs in connection with exposure to cold or 
extensive burns of the skin and in connection with all acute infectious 
diseases, particularly scarlatina, measles, and cholera infantum, and it may 
be due to the toxic irritation of turpentine, potassium chlorate, cantharides, 
carbolic acid, etc. 

Symptoms. — The urine becomes scanty and high colored or smoky in 
appearance, and is found to contain blood, albumin, and epithelial and blood 
casts. The fever is variable. There is a hard pulse. The face and ankles 
may be puffy and swollen. There may be general oedema or a localized 
cedema of the glottis and the lungs. Uremic symptoms, coma and con- 
vulsions, are not uncommon, and as regards severity all grades are en- 
countered. 

Prognosis. — The outlook varies with the underlying cause. In children 
the most severe forms of nephritis may end in complete recovery; in some 
instances a kidney will clear up in two weeks, or it may take several months 
before the symptoms completely subside. A rapidly fatal form is occa- 
sionally encountered. 



CHRONIC PARENCHYMATOUS NEPHRITIS 



479 



Treatment. — The patient suffering from nephritis, whether primary 
or secondary, should rest in bed and have his bowels moved by calomel and 
a saline cathartic. 

Diet. — Water, milk, slimy gruel, beef tea, peppermint tea, black tea, 
chicken broth, matzoon, buttermilk, arrowroot, cornstarch and custard, 
ice cream, and alkaline mineral waters may be allowed. 

Enteroclysis at 110° F. should be practised once or twice a day to 
stimulate the kidney secretion. When there is pronounced kidney insuffi- 
ciency, we call upon the skin and the boioels to perform eliminative work. 
The skin is influenced by means of hot tub baths, hot air baths, and the 
hot pack; the bowels may be made to move by the administration of saline 
cathartics, such as sulphate of sodium. Should the skin remain hot and dry, 
from £ to tV 01 a grain of pilocarpine may be given three or four times a 
day to children, and double this dose to adults. Infusion of digitalis, in 
teaspoonful and tablespoonful doses, will increase the kidney secretion 
by increasing arterial pressure. If the heart is very much embarrassed, 
venesection should be done, and when there is complete suppression of urine 
the kidneys should be exposed by a lumbar incision and renal tension over- 
come by splitting the kidney capsule. 

CHRONIC NEPHRITIS (CHRONIC BRIGHT'S DISEASE) 

Clinically, we are able to recognize two forms: Chronic diffuse nephritis 
(parenchymatous nephritis) and interstitial nephritis (cirrhosis) . 

Chronic Parenchymatous Nephritis 

This form corresponds somewhat to the hypertrophic cirrhosis of the 
liver. Such a kidney, when seen in vivo, is very large, reddish blue in color, 
and has a thin capsule which can easily be stripped off. Post mortem such 
a kidney is large and has a whitish appearance, but occasionally it appears 
small and white. It is met with in young adults and in children, follow- 
ing infectious diseases or acute nephritis from the various causes already 
enumerated. 

Symptoms. — The cardinal symptoms are dropsy, anaemia, and urinary 
changes, and associated with them may be headache, nausea, vomiting, and 
urcemic manifestations. The marked anaemia and puffy eyes are character- 
istic. The pulse is accelerated and of high tension, and, owing to circula- 
tory obstruction, the heart soon shows secondary hypertrophy. The urine 
is scanty and turbid. The sediment shows epithelial casts, leucocytes, and 
red blood cells, and albumin is abundant. The urea is reduced in quantity. 
Retinal changes occur and gastrointestinal symptoms are common. 

Prognosis. — The prognosis is grave. Recovery is rare in cases which 
persist for a year and over. Death may come suddenly or in uraemic coma 
associated with general dropsy. 

Treatment. — The medicinal and hydrotherapeutic management is prac- 
tically the same as in acute nephritis. If the patient is waterlogged and 
the heart is embarrassed, venesection, scarification of the lower extremities, 
and the administration of digitalis and other diuretics are indicated, as 
discussed under Dropsy. 



480 



THE GENITOURINARY SYSTEM 



Diet. — As chronic nephritis is undoubtedly accompanied by a reduction 
in the output of urea and chlorides, a not too rigid vegetable and saltjree diet 
appears indicated. 

In cases tending to chronicity, it is unnecessary to persist in a fluid diet. 
A plain miscellaneous diet is indicated, avoiding cheese, cabbage, pastry, 
beans, fried sea food, beer, spirits, coffee, and tea. The patient may take 
raw oysters, raw clams, fresh fish, beef and mutton in moderation, chicken, 
salads, game, good bread, hominy, wheaten grits, rice, toast, oatmeal, 
gruels, spinach, summer cabbage, turnip tops, water cresses, lettuce, mush- 
rooms, celery, rice and milk puddings, fruits. He may drink water abun- 
dantly, hot water, milk, skimmed milk, buttermilk, and mint tea. If there is 
much digestive disturbance and if perfect mastication is not performed, 
the meats may be scraped or finely chopped, made into balls, and broiled. 
In some instances experience will indicate a radical change, and a milk or 
vegetable diet will best answer. When this management is of no avail, 
renal decapsulation, as practised by Edebohls, may be indicated. 

Five drops of dilute hydrochloric acid in water should be given after 
each meal, to aid digestion. Mild general massage is also indicated. 

For the management of Dropsy see Dropsy and Effusion. 

Chronic Interstitial Nephritis; Cirrhosis of the Kidney; Contracted Kidney 

In this form of nephritis the kidney, when seen in vivo or post mortem, 
is small, hard, contracted, and nodular, with an adherent thick capsule. 
Clinically, we notice that dropsy is not a marked feature and that cardio- 
vascular changes are pronounced. A tendency to this form of kidney 
degeneration runs in some families. Syphilis, alcoholism, gout, arterio- 
sclerosis, and high living are factors in its production, or are associated 
features. Hypertrophy of the heart is constant. 

Symptoms. — Increased arterial tension is the most important early 
symptom. The patient complains of malaise, headache, heart palpitation, 
cough, dizziness, ringing in the ears, and loss of appetite, and the tongue 
is coated. In due time enlargement of the heart is evident, followed by 
retinal changes, ursemic amaurosis, sudden blindness, and cerebral apoplexy. 
The skin is dry and pale, the ankles may be puffy, and haemorrhage and pur- 
pura may develop. Sudden oedema of the glottis may occur, also acute 
pulmonary oedema, and ursemic coma and convulsions often end the scene. 
The urine is abundant, of low specific gravity, and contains albumin and a 
few casts. 

Prognosis. — Chronic Bright's disease may be called incurable, but the 
patient may live in a fairly comfortable condition for many years. Arte- 
riosclerotic degeneration is a slow process and may not affect both kidneys 
alike. One kidney may be completely degenerated and the other one only 
partly so, in which event life may be sustained until both organs are insuffi- 
cient in function. 

Treatment. — Medication will not arrest kidney degeneration. If the 
patient has contracted syphilis in early life, it would be wise to administer 
mercurials and iodides with the hope of arresting the vascular changes 
which may affect any organ. In chronic malarial disease with nephritis 



UREMIA IN NEPHRITIS 



481 



a course of quinine is advisable. Beyond these two points medication is 
useless. A quiet life in an equable climate and a plain mixed diet should 
be recommended, avoiding meats and salt as much as possible. In the 
way of drinks, good water, tea, coffee, mint tea, and ginger ale may be 
allowed; two ounces of whiskey may be taken in water in twenty-four 
hours. The bowels should move once a day. Five drops of hydrochloric 
acid after meals will aid digestion. Mild general massage three times a 
week is helpful on account of its influence on the circulation. For high 
arterial tension, venesection followed by nitroglycerine is indicated. 

Dyspnoea and insomnia are distressing symptoms in Bright's disease 
from which subcutaneous injections of morphine, gr. \ to \, with or without 
atropine, will give relief. The management of dropsy will be found in 
the chapter on Dropsy and Effusion. 

THE SURGICAL TREATMENT OF ACUTE AND CHRONIC NEPHRITIS 

Acute renal infection is occasionally so intense as to lead to a rapid and 
fatal termination. When renal tension can be relieved in no other way, 
an incision through the capsule of an acutely inflamed kidney is indicated and 
may establish a cure. Reginald Harrison, of England, has reported since 
1896 a number of such cases and cures. 

The proposition to treat chronic nephritis surgically was first made by 
Dr. G. M. Edebohls, of New York, in April, 1899, after various observers, 
including himself, Rose, Ferguson, and Newmann, had noticed the dis- 
appearance of albumin and casts from the urine after operations upon the 
kidney. 

Nephritis following acute infectious diseases in children has a tendency 
to complete recovery. Children who survive the acute stage, but continue 
to show albumin and casts for several months, also make a complete re- 
covery in the majority of cases. In a small percentage of cases recovery 
does not take place. 

Patients who are affected with nephritis following diphtheria, scarlatina, 
measles, or malarial disease in early life may not entirely recover. Kidney 
insufficiency with ursemic symptoms and convulsions may develop at any 
age and is frequently manifested at the time of the first confinement. 

In view of the uselessness of medication in chronic nephritis, the physi- 
cian is justified in advising inspection of the kidney through a lumbar 
incision in cases in which an acute nephritis, not secondary to heart lesions, 
does not clear up in from six months to a year, and in suggesting decap- 
sulation of one or both kidneys if they appear swollen and enlarged. For 
detailed information on this subject the reader is referred to Dr. Edebohls's 
monograph, The Surgical Treatment of Blight's Disease, 1904. 

Uramiia in Nephritis 

The symptom complex known under this name is probably due to re- 
tention within the circulation of poisonous materials which should be 
eliminated in the urine. The exact nature of these poisons is not def- 
initely known. It has been suggested that so called unemic coma and 



482 



THE GENITOURINARY SYSTEM 



convulsions are due to oedema of the brain. Two urinary findings are 
practically constant in uraemia, viz.: a reduction of the amount of urea 
and the presence of tube casts. 

Uraemia in the course of nephritis is a grave condition. 

Symptoms. — The symptoms are headache, sleeplessness, coma, convul- 
sions, paralysis, amaurosis, nausea, vomiting, delirium, dyspnoea, and 
increased arterial tension. The temperature may be normal, subnormal, 
or elevated. 

In ursemic coma the history of Bright 's disease may often be elicited; 
the onset is usually sudden with delirium and convulsions. The face is 
waxy pale, the body cedematous, the breathing stertorous, the pulse full 
and strong, usually slow, and the urine scanty and showing albumin and 
casts. Toward the end the Cheyne-Stokes type of breathing may occur. 
This condition may be more or less acute and rapidly fatal or persist for a 
long time. 

Prognosis. — The prognosis is grave, but in the mild form recovery is 
possible. For differential points between the various forms of coma, see 
Coma. 

Treatment. — Treatment of an acute ursemic attack: Venesection and 
enteroclysis are rational and safe procedures in ursemic coma or convulsions. 
Chloral hydrate, gr. x to xxx, per rectum, or morphine subcutaneously, 
gr. I, should be employed with great caution, as they are apt to overpower 
the heart. Chloroform inhalations sometimes give relief. Pilocarpine, in 
tV to | grain doses, may be given with the hope of promoting diaphoresis. 
In desperate cases renal decapsulation may be employed. 

PYELITIS AND PYELONEPHRITIS; PYONEPHROSIS; SURGICAL KIDNEY 

The pelvis of the kidney may be the seat of inflammation which may 
have traveled upward from the bladder or may be primary in the kidney 
with a tendency to travel downward. The causative factors are calculi, 
tuberculosis, gonorrhoea, and all acute infectious diseases, such as typhoid 
fever, etc. 

Symptoms. — The mild cases of pyelitis often pass unnoticed and re- 
covery is complete in a few weeks. When suppuration has set in, there 
is a rise of temperature with chills and sweating, and the urine, though it 
usually remains acid, becomes turbid and shows blood and pus. The 
patient has a dull pain in the lumbar region of the affected side. In the 
chronic cases there is a persistence of all the symptoms in a mild way, with 
an evening rise of temperature. The general health fails, as in all wasting 
diseases, but the patient may live for years in comparative comfort. The 
writer is familiar with a case of suppurative pyelitis of twenty-two years' 
standing. The patient, a man fifty years of age and of good physique, is 
able to manage a large business and declines operative interference because 
he has neither pain nor urgent symptoms. In another class of cases the 
kidney is honeycombed with pus (surgical kidney) and shows tenderness on 
palpation. The septic symptoms are more severe in this class of cases, 
and unless they are relieved the patient succumbs. 

The diagnosis rests upon the septic symptoms and the presence of pyuria. 



SURGICAL KIDNEY 



483 



The question of which side is affected can be answered by the local tender- 
ness on palpation and by separately collecting the urine by means of the 
Harris segregator or ureteral catheterism. Kidney stones may be detected 
by means of an x ray examination, and tuberculosis of the kidney can be 
diagnosticated if on repeated examinations of the urine the tubercle bacilli 
are found. 

Differential Points. — In suppurative cystitis the urine is alkaline, and 
tenesmus and pain are localized in or about the bladder; lumbar pain is 
more suggestive of pyelitis. In perinephritic abscess the pus does not 
escape through the urine; the lumbar region is tender on palpation, appears 
swollen, and may be cedematous. 

Treatment. — In mild cases the kidney should be flushed by drinking 
liberally of water, mineral water, and mint tea. Disinfection of the urinary 
passages may be attempted by administering urotropin in 10 grain doses 
three times a day or methylene blue in 2 grain doses three times a day, 
to be given in capsule. Warm tub baths and sponge baths and a light 
nutritious diet are indicated. If a slow and steady improvement is manifest, 
operative interference may be deferred. Calculi, when diagnosticated and 
located, may be cut out. The diagnosis of tuberculosis of the urinary 
tract should not be accepted from any but an experienced microscopist, on 
account of the similarity of the harmless smegna bacillus to the tubercle 
bacillus. Mistakes of this nature have been made and kidneys "have been 
unnecessarily sacrificed. Before a kidney is extirpated we must be sure 
that the other kidney is performing its function. 

In the severe forms of pyelitis we have at our command the following 
plans of treatment: 

Expectant treatment, with rest, the use of diluents and drugs, such as 
urotropin and salol. 

The local treatment of a cystitis, especially those forms adjacent to a 
ureteral orifice. 

Incision or dilatation of a stricture of a ureteral orifice. 

Catheterization of the ureter and renal pelvis. 

Irrigation of the ureter and renal pelvis. 

Distention of the renal pelvis. 

Instillations into the renal pelvis. 

Permanent catheterization of the renal pelvis for some hours or days. 
Nephrotomy (nephrolithotomy). 

Nephrostomy for more or less permanent drainage through the side. 
Nephrectomy in the advanced cases of pyelonephritis or pyelonephrosis. 

PERINEPHRITIC ABSCESS 

This ailment is occasionally overlooked. It may occur primarily from 
injury with infection, or secondarily by the extension of a neighboring 
inflammation. 

Symptoms. — Localized pain and swelling, with fever, chills, and sweating, 
are noticeable in pronounced cases. The pain is deep seated in the lumbar 
region and may radiate into the thigh and genitals. The swelling may show 
fluctuation and present an cedematous appearance. There is percussion 



484 



THE GENITOURINARY SYSTEM 



dulness in the flank, and bimanual palpation reveals a swelling or indurated 
mass. The urine is clear unless pyelitis is also present. In doubtful cases 
the use of the aspirating needle may be necessary for the diagnosis, and when 
pus is found the tumefaction must be incised and treated like any other 
abscess. A perinephritic abscess may be mistaken for appendicitis, empy- 
ema of the gall bladder, psoas abscess, or lumbago. When free drainage 
can be established the prognosis is good. 

MOVABLE KIDNEY; FLOATING KIDNEY (NEPHROPTOSIS) 

We recognize various degrees of abnormal kidney mobility. We speak 
of palpable kidney, movable kidney, floating kidney, and fixation of the 
kidney in an abnormal position. Floating kidney is rather common in 
women and is generally acquired, owing to the wasting of fat around the 
kidney or the relaxation of abdominal walls in consequence of repeated 
pregnancies and as an element of that general relaxed condition known as 
enteroptosis. The condition is recognized by means of bimanual palpation 
in the lying or standing posture. The patient aids in the examination 
by taking a deep inspiration, and when a kidney is quite out of place we 
notice a distinct flattening of the lumbar region on the side on which the 
kidney is loose or mobile. The recognition of a movable kidney in moder- 
ately nourished women, when a part or the whole organ can be palpated, 
does not present a difficult problem; but when the abdominal wall is thick, 
when the symptoms point to gallstones, impacted in the cystic or common 
ducts, or to a false or dislocated lobe of the liver, if the spleen or pancreas 
has become loosened, if the kidney is but slightly movable, if a third kidney 
is present, or if a congenital kidney presents, whether freely movable or 
attached to the false or true pelvis, when associated with gastroptosis, 
enteroptosis, uterine displacements, or other pelvic disorders, the diagnosis 
demands careful study. The displaced kidney can usually be felt as a 
tumor which can be replaced. The diagnosis of floating kidney should be 
made by palpation and never by the symptoms. The hepatic flexure of the 
colon has been mistaken for movable kidney. 

Symptoms. — Dyspepsia, with motor, sensory, and secretory neuroses of 
the various abdominal viscera, is noticed in cases of floating kidney, but 
it is also a common complaint of hysterical and neurotic individuals. Pain- 
ful crises, mucous colitis, hydronephrosis , and intermittent albuminuria have 
disappeared after fastening a movable kidney. The relation of movable 
kidney to Bright's disease and to appendicitis is of interest. According 
to the experience of Edebohls chronic appendicitis is the chief symptom and 
most important complication of movable right kidney. A dragging sen- 
sation and a feeling of weakness are the general symptoms in movable 
kidney. 

Treatment. — When kidneys have become displaced from loss of fat in 
general emaciation, the patient may with benefit adopt the rest cure. 
Ordinary degrees of mobility can be benefited by wearing a plain abdomi- 
nal supporter, or belt, which encircles and sustains the lower two thirds of 
the abdomen. All forms of apparatus with special kidney pads are use- 
less or injurious. In lieu of a bandage a straight front corset which comes 



SUMMARY OF DIAGNOSTIC POINTS IN KIDNEY LESIONS 485 



low down and properly supports the lax abdomen can be worn to advan- 
tage. Such a corset is best applied when the woman lies on her back. A 
floating kidney may be anchored in its proper place by operative means 
(nephropexy), and torsion symptoms are the principal indications for 
operation. 

SUMMARY OF DIAGNOSTIC POINTS IN KIDNEY LESIONS 

Tumors. — Tumor, pain, hematuria, cachexia, sarcoma in early life, 
carcinoma in later life. 

Cysts. — Tumor, pain, discomfort, cloudy urine, cyst fluid on aspiration. 
Cysts are congenital or acquired. 

Hydronephrosis. — History of torsion or blocking of ureter; painless, 
fluctuating unilateral tumor may be bilateral. 

Floating Kidney. — Pain, neurasthenia, recognition of displacement by 
examination. 

Pyelonephritis (Surgical Kidney). — Irregular low fever, occasionally chills 
and high temperature, pyuria, cystitis, sometimes enlargement and ten- 
derness to touch. History of obstruc- 
tion, stricture, large prostate, calculi 
plus infection (gonorrhoea or pus in- 
fection), or infection following preg- 
nancy, abortion, and pelvic infection 
in women. 

Tuberculous Pyelonephritis. — Con- 
stant irregular fever, chronic course, 
frequency of urination, hsematuria, 
pyuria, tuberculous history, marked 
secondary ansemia. 

Chronic Nephritis. — Constant al- 
buminuria, casts, decrease in urea 
elimination, secondary enlargement 
of the heart, renal and cardiac dysp- 
noea, general or local dropsy, retini- 
tis albuminurica. 

THE URETERS 

The ureters are liable to become 
obstructed by calculi or constricting Ue 
bands Or by the pressure of tumors. Fig. 154.— Sacculated Prolapse of the 
They may participate in the ulcera- Right Ureter. 

tive tuberculous processes of the gen- 
itourinary tract. Torsion and kinking of the ureters sometimes take place 
in floating kidneys and give rise to painful crises, known as Dietl's crises. 
In such cases one sided pain or colic is usually present. By means of the 
Harris segregator or catheterism of the ureters we may definitely ascertain 
which side of the urinary tract is involved. Injury to the ureters is pos- 
sible in major pelvic and abdominal operations. Prolapse of the inverted 




486 



THE GENITOURINARY SYSTEM 



lower portion of the right ureter into the bladder and through the urethra, 
in a child two weeks old, was reported by the writer in the American Jour- 
nal of the Medical Sciences for May, 1888. 

Total extirpation of the ureter has been done in connection with ex- 
tirpation of the kidney for malignant growths or calculous and tuberculous 
diseases (see case of Dr. Willy Meyer in the Jacobi Festschrift, 1900). 

AILMENTS OF THE URINARY BLADDER 

General Remarks. — The empty bladder lies behind the symphysis pubis. 
When the bladder is extremely full and distended, its percussion dulness 
may reach to and above the umbilicus. The neck of the bladder is sur- 
rounded by the prostate, and both are immovable. Suprapubic and recto- 
vesical and vaginovesical palpation are readily performed. The intro- 
duction of the sound will determine the condition of the vesical walls or the 
absence or presence of calculi and foreign bodies. 

Visual inspection is possible by means of the cystoscope. Digital ex- 
ploration is possible through a suprapubic or perineal incision and in the 
female through the dilated urethra. Direct visual inspection of the bladder 
in women is best accomplished by Kelly's method with the patient in the 
knee-chest position. 

Patent urachus, the remains of a fcetal structure (see section on Paedi- 
atrics). 

Exstrophy of the bladder is an absence of its anterior wall with deficiency 
in the corresponding abdominal wall. This condition can be remedied by 
a plastic operation described in special surgical works. 

Vesical diverticula are sometimes met with. Various injuries, such as 
contusions and perforating wounds, resulting in rupture of the bladder, are 
met with and are of a serious nature when extravasation of urine results. 
When rupture is suspected, a soft catheter should be introduced into the 
bladder. If the urine comes away bloody, a measured quantity of boric 
acid solution should be injected into the bladder. In case of rupture, the 
full quantity of liquid cannot be regained by catheterism, and immediate 
surgical treatment may become necessary. Inversion of the bladder through 
the female urethra has been observed. In such cases the viscus presents 
in the form of a bluish pink sac. 

Vesical hypertrophy is seen in cases in which an obstruction to the 
flow of urine has developed gradually. When a fistulous opening be- 
tween the bowel and bladder exists, foul gas and faecal matter will be ex- 
pelled with the urine. Vesicovaginal fistula may occur from childbirth 
and from injury. 

Vesical neuroses and irritability of the bladder are usually of a reflex 
nature, depending upon disease of neighboring organs. A marked irrita- 
bility of the bladder is occasionally observed in cases of appendicitis. 
Neurotic individuals, adults as well as children, urinate frequently. On 
the other hand, neurotic retention of urine is not uncommon. Retention 
is often observed after childbirth or following operations on the rectum 
and penis. The inhibitory effort is due to the dread of exciting pain. In 
such cases the application of a hot water bag is often efficacious. Noc- 



ACUTE CHRONIC AND ULCERATIVE CYSTITIS AND PERICYSTITIS 487 



turnal incontinence in children is discussed in the section on Paediatrics. 
In some neurotic individuals there may be a local irritation due to the 
deposit of crystals in the urine. When a cystoscopic examination is 
made in a case of irritable bladder, a localized hypercemia of the trigonum 
is often found. In protracted cases of this nature a few applications of a 
5 per cent solution of nitrate of silver directly to the red patches will have 
a curative effect. 

Paralysis and atony of the bladder, with retention or incontinence, are 
met with in serious lesions of the central nervous system, as in locomotor 
ataxia and spinal sclerosis. The treatment for such conditions must be 
directed to the underlying cause, and when syphilis of the nervous centres is 
suspected, energetic antisyphilitic treatment is indicated. In cases of in- 
curable incontinence a rubber urinal may be worn by the sufferer. 

ACUTE CHRONIC AND ULCERATIVE CYSTITIS AND PERICYSTITIS 

Causes. — Cystitis is due to chemical or mechanical irritation combined 
with infection. Calculi, foreign bodies, unclean catheters, foul urine, 
tumors, and syphilitic and tuberculous ulcers are causative factors. Cystitis 
may be due to the extension of a neighboring inflammation, as in gonorrhceal 
urethritis. Cystitis is occasionally a complication in the course of infectious 
fevers. In some instances an examination of the bladder shows nothing 
more than redness at the trigonum. In other cases the cystoscope will 
reveal ulceration or a bullous oedema of the mucous lining of the bladder. 
In chronic cystitis the vesical walls are usually very much thickened. 

Ulceration in the bladder may be due to traumatism, thrombosis of 
veins, pus infection, syphilis, tuberculosis, or carcinosis. Hcematuria is 
generally observed in such cases. 

Symptoms. — The symptoms of cystitis are characteristic; dysuria, pain 
on pressure over the pubic region, and cloudy urine loaded with bladder 
epithelia and pus cells or blood. The urine soon acquires an ammoniacal 
odor and may become putrid. Fever is usually present, and in a severe 
form the patient has chills. A vesical neurosis is often taken to be cystitis; 
in the former the urine is free of pus. 

Differential Diagnosis of Cystitis and Pyelitis. — The reaction of the urine 
in pyelitis not associated with cystitis is acid. The white blood corpuscles 
in cystitis have a rounded contour, those from the kidney pelvis have dis- 
torted forms. In cystitis with marked pyuria the albumin rarely exceeds 
from 0.1 to . 15 per cent. In pyelitis with little pyuria the albumin ranges 
from 0.15 to 0.3 per cent. 

Treatment. — The treatment is radical or palliative. In catarrhal cys- 
titis with superficial simple ulceration, in which palliative treatment is of 
no avail, local cauterization may be indicated. Tuberculous ulceration 
may require direct local treatment in cases in which bladder irrigation 
with boric acid solution or with iodoform emulsion fails to give relief. 

The radical treatment is directed to the primary cause. The palliative 
treatment consists of rest in bed, opium and belladonna suppositories, sub- 
cutaneous injections of morphine, and the free administration of warm 
drinks (flaxseed tea or peppermint tea). If the symptoms are urgent, it 



488 



THE GENITOURINARY SYSTEM 



may be well to irrigate the bladder by means of a fountain syringe and a 
soft rubber tube once or twice a day with some mild antiseptic solution, 
such as boric acid solution (2 per cent) or formalin solution (5 to 10 min- 
ims to a pint). In chronic cystitis vesical drainage and direct local treat- 
ment in conjunction with hygienic measures may be called for. Drainage 
may be effected through a perineal incision a suprapubic incision, or, in 
the female, through the vaginal fornix. 



STONE IN THE GENITOURINARY TRACT 



GLASS T CANNULA 



Concretions, or stones, are found in both sexes and at all ages in the 
kidneys, ureters, bladder, urethra, and occasionally the prostate gland 
and the seminal vesicles. The general symptoms of stone in the urinary 

tract are pain, local ten- 
derness, colic, hcematuria, 
pyuria, and a paroxysmal 
fever which is often mis- 
taken for atypical mala- 
rial fever. The passage 
of calculi makes the diag- 
nosis positive. In making a diagnosis we re- 
quire time, a good history, a physical and urin- 
ary examination, and possibly cystoscopy, 
radiography, ureteral catheterism, and explor- 
atory incision. 




* s' Stone in the Kidney 

Fig. 155.-For Bladder Irri- In addition to the general symptoms just 
gation. mentioned, the urine shows albumin and casts, 

the pain is often paroxysmal and intense, ac- 
companied by nausea and fainting, and radiates downward into the thigh 
and the pubic region. Frequent micturition is generally present. A posi- 
tive diagnosis is often impossible, ynless the patient has been under obser- 
vation for some time. Therefore surgical interference should not be hastily 
carried out except in cases of urgency and complete obstruction. Fine 
gravel may be passed for years without giving rise to marked symptoms, 
and gravel is occasionally found in the diapers of infants. An attack of 
renal colic is usually followed by a feeling of general prostration, and an 
aching pain is complained of in the region of the affected kidney. 

Differential Points. — In biliary colic the pain is localized more toward 
the middle line and is apt to radiate into the back, and frequently there is 
jaundice. A floating kidney is made out by a physical examination. In 
some instances appendicular colic or intestinal colic may be confounded 
with renal colic, particularly in fat individuals. In such cases the correct 
diagnosis is made after a small stone is found to have passed with the urine. 
A stone in the ureter can occasionally be felt through a lax abdomen, par- 
ticularly when the patient is examined under ether. Calculi in the ureter 
give the usual colicky and retention symptoms on one or on both sides. 
Impacted stones may cause ulceration and perforate through the ureters. 



STONE IN THE URINARY TRACT 



489 



Stone in the Bladder 

Stone in the bladder gives rise to frequent micturition and tenesmus and 
causes ammoniacal or cloudy urine. Prolapse of the rectum is occasionally 
present in connection with stone in the bladder. The stone may be detected 
by sounding the bladder or by digital examination by the rectum or vagina. 
Stone in the urethra produces strangury, hematuria, and retention of urine. 
Stone in the prostate and in the seminal vesicles may be suspected in all in- 
flammatory conditions in these organs. In obscure cases, in which stone is 
suspected somewhere in the genitourinary tract, an examination with x rays 
is of importance, or an exploratory nephrotomy should be done. In at- 
tempting to examine a patient with the x ray, the bowels and bladder 
should be empty and the patient should be placed upon his belly on a large 
sensitive plate. The tube is fixed so as to be over the umbilicus, about 
eighteen inches from the plate. Calculi of oxalates or phosphates give 
the best shadows. The fluoroscope is not suitable for this kind of work. 

Prognosis. — Renal calculi may pass for years without giving alarming 
symptoms. Frequent attacks of colic and the evidence of an inflammatory 
condition of the genitourinary tract, as shown in the urine, call for radical 
treatment. 

Differential Points. — In tuberculosis of the genitourinary tract there 
is marked cachexia, tubercle bacilli are sometimes found in the urine, and 
there may be a family history of tuberculosis. In malignant tumor there 
are marked cachexia, loss of weight, and a palpable tumor. In movable 
kidney there is an absence of hematuria and pyuria. The kidney is palpable 
and can be replaced. In vesical inflammation from stone or tuberculosis 
in the bladder, the epithelia in the urine will be vesical. A rectal and 
cystoscopic examination will give additional proof of the bladder trouble. 
Ulcer of the stomach and aneurysm of the aorta may give rise to symptoms 
somewhat akin to those of renal colic. A careful examination will reveal 
the origin of the pain. Careful palpation will make out a large kidney; 
a stone in the kidney can never be felt. Before operating upon one kidney, 
the condition of the kidney on the other side should be carefully looked 
into, as explained elsewhere. 

Treatment. — An attack of stone colic is best managed by administering 
morphine hypodermically in \ to \ grain doses. Rest in bed and a fluid or 
semisolid diet should be insisted upon. A hot water bag should be placed 
over the seat of the pain. The urine which passes must be carefully ex- 
amined for bile, blood, blood pigments, and concretions. 

Should palliative treatment fail to relieve the patient, or should frequent 
attacks foreshadow a severe inflammatory condition of the genitourinary 
tract, radical surgical treatment is indicated and often gives satisfactory 
results. If nephrolithotomy can be performed before the kidney is ex- 
tensively destroyed, the fatality attending such an operation is not above 
10 per cent. With extensive destruction of the kidney the mortality reaches 
50 per cent. After the passage or the operative removal of stones, the 
after-treatment will consist in the administration of large quantities of 
pure water or aromatic tea, such as peppermint tea, with a view of over- 
coming the tendency to stone formation. Urotropin, in 10 grain doses 



490 



THE GENITOURINARY SYSTEM 



three times a day, may be given for some weeks or until the urine appears 
to be clear. After the removal of the stone from the bladder by a crushing 
or cutting operation, another stone may make its appearance after a time. 
This may be due to an erosion of the bladder mucosa which favors the 
deposit of urinary salts, or a second stone may have come down from the 
kidney or have been overlooked before. In one instance the author ob- 
served in a young woman the passage of small stones with short and long 
hairs attached. These stones came down from a dermoid broad ligament 
cyst which had ruptured into the bladder. 

The causes which lead to stone formation are not well understood. 
Generally speaking, all pathological changes in the urinary tract favor the 
precipitation of urinary salts. On the other hand, there are cases in which 
stone formation appears to be the primary lesion. 

SYPHILIS OF THE GENITOURINARY TRACT 

Syphilitic disease of the genitourinary tract cannot positively be dis- 
tinguished from other inflammatory and degenerative processes, except 
by the therapeutic test (the administration of mercury and potassium 
iodide) and by taking into consideration the clear cut history of syphilitic 
infection. In doubtful cases the patient should always have the benefit of 
the doubt and receive the antisyphilitic management, which is fully described 
in the chapter on Syphilis. Renal syphilis is supposed to assume the form 
of amyloid degeneration. The body of the testicle may show syphilitic 
tumefaction, and the bladder may suffer by reason of syphilitic ulceration. 

TUBERCULOSIS OF THE GENITOURINARY TRACT 

The genitourinary organs may participate in a general miliary tuber- 
culosis. The insidious and chronic tuberculosis in this region may start in 
the kidney and travel to the bladder, or vice versa. Infection certainly 
takes place through direct contact, as shown by the infection of the husband 
by the wife or the wife by the husband. In some instances renal and vesical 
tuberculosis is observed in individuals in whom there is absolutely no 
evidence of tuberculosis anywhere else. This may be explained by assum- 
ing that the infecting tubercle bacilli have actually entered the circulation 
and have subsequently lodged in the kidney instead of elsewhere. Primary 
tuberculosis of the prostate and epididymis is not infrequently the starting 
point of the general infection of the genitourinary tract, but we find it more 
frequently secondary to pulmonary or intestinal tuberculosis. 

Diagnosis. — A turbid urine mixed with blood is the first characteristic 
symptom of the disease. Tuberculous pyelonephritis presents the following 
clinical picture: There is polyuria with lowered specific gravity and acid 
reaction, the urine is pale in color, its odor is not offensive, and it contains 
albumin, pics, blood, a profuse sediment, a few casts and renal epithelia, 
some bladder epithelia, and tubercle bacilli. A definite conclusion as regards 
the involvement of one or both kidneys must be arrived at by a cystoscopic 
examination and an examination of separately collected urine. One of the 
most valuable signs of tuberculosis of the kidney is the marked change at 



TUBERCULOSIS AND NEW GROWTHS OF GENITOURINARY TRACT 491 



the orifice of the corresponding ureter. In obscure cases the tuberculin 
test may be of value. The positive diagnosis is made with the microscope. 
As the smegma bacillus shows great similarity to the tubercle bacillus, special 
methods of staining should be practised, and cultures and animal inoculations 
may be necessary to avoid error (see Laboratory Aids to Clinical Diagnosis). 

TUBERCULOSIS OF THE BLADDER 

Primary vesical tuberculosis is very rare. We find the disease more fre- 
quently associated with tuberculosis of the prostate and seminal vesicles. 
It gives the symptoms of a chronic cystitis. Frequency of micturition 
becomes marked, the pain is severe, and haemorrhage is not unusual. The 
general health becomes greatly impaired. An examination with instruments 
is painful and usually accompanied with haemorrhage owing to the ulcerated 
condition of the bladder in such cases. 

Diagnosis. — The diagnosis of primary cases is often so difficult that a 
suprapubic cystotomy may be indicated for diagnostic purposes and for 
the purpose of draining the bladder with the hope of giving relief and 
effecting a cure by keeping the bladder at rest. 

Treatment. — A strictly localized tuberculosis of one kidney or of the 
prostate gland or the testicle may be cured by the prompt extirpation of 
the infected part. When such a course is not feasible or indicated, the 
general hygienic management for tuberculosis should be carried out, and 
palliative treatment, as described under Chronic Cystitis, should be adopted. 

BENIGN AND MALIGNANT NEW GROWTHS 

Benign tumors and cysts of the kidney do not always give rise to renal 
symptoms ; occasionally a kidney is found to be entirely transformed into a 
multilocular, simple, or hydatid cyst. The diagnosis is made by means of 
bimanual palpation, by exploratory puncture, or by exploratory incision. 
The treatment is surgical. Malignant renal growths are not rare; they 
are found at all ages, even in children. Haematuria is present in about 50 
per cent of such cases. A visible tumefaction is noticeable and a tumor is 
made out by palpation. Paranephritic cysts may be of traumatic origin. 
They present a fluctuating tumor holding a chocolate colored fluid. 

Differential Points. — Neoplasms of the retroperitoneal glands are more 
centrally located and usually immovable. Tumors of the left kidney are 
frequently mistaken for splenic tumors. In cases of enlarged spleen the 
percussion dulness is absolute over the tumor, whereas in renal tumors the 
inflated colon usually crosses the renal tumefaction and gives a tympanitic 
percussion sound. The spleen has a characteristic outline and moves with 
respiration. 

Prognosis and Treatment. — Benign neoplasms give but little trouble. 
Malignant tumors involve an unfavorable prognosis; when their radical 
removal is possible it should be done. Sarcoma of the kidney has been radi- 
cally and successfully removed in children of a tender age. When operative 
interference is out of the question, every effort should be made to make the 
patient comfortable, and no restrictions as regards food, alcohol, or tobacco 
should be suggested or enforced. 



492 



THE GENITOURINARY SYSTEM 



Hydronephrosis is discussed in the chapter on Dropsy. 

Benign and Malignant Tumors of the Bladder. — Polyps, cysts, and 
malignant and benign solid tumors give symptoms of chronic cystitis and 
usually demand surgical treatment. Pericystic inflammation may be sub- 
dued by applying hot water bags. Should pus form, a free incision is in- 
dicated. 

Congenital malformations and defects of the kidney are occasionally 
met with. Some persons have but one kidney, others have supernumerary 
kidneys, some kidneys have a horseshoe shape, etc. 

Injuries to the kidneys are recognized by the accompanying hematuria 
in connection with the history of traumatism. According to the extent and 
nature of the injury, palliative treatment, rest with opiates, or surgical 
interference is called for. 

PARASITES OF THE GENITOURINARY TRACT 

Strongulus gigans (palisade worm), distoma haematobium, and filaria 
sanguinis are parasites which may be taken into the system with the drinking 
water, and are found in the urine of persons who live in a tropical climate. 
They give rise to lymphatic obstruction and to symptoms of pyelitis. The 
urine in such cases is milky. This condition is known as chyluria. 

Filaria is a worm several inches long, which may live for years in the 
lymphatics. Thymol, 1 to 10 grains, several times a day, and methylene 
blue, 2 grains every four hours, have been given internally to destroy the 
parasite. The clinical symptoms of Bilharzia hcematobia arise from the 
burrowing of the eggs in connection with their hatching. The symptoms 
are hcematuria, pain, and tenesmus; granulation tumors have been known 
to form in the mucous membrane of the bladder; and eventually renal 
obstruction and suppuration may supervene. A positive diagnosis is made 
by finding the ova or embryos in the urine. The treatment by the ad- 
ministration of male fern has not given satisfactory results. Surgical means 
have been employed in suppurative cases. 

Echinococcus. — The cyst of echinococcus may involve the kidneys and 
the bladder, giving rise to symptoms of pyelitis or cystitis. The hooklets 
of the parasite may be found in the urine. The treatment is surgical, par- 
ticularly where there is tumor formation. 

Pediculi pubis are animal parasites having their habitat in the hairy part 
of the pubic region, as described in the dermatological memoranda. 

LOCALIZED AND MINOR AILMENTS OF THE MALE GENITAL ORGANS 

Penis 

Epispadias, or congenital opening of the urethra on the upper part of 
the penis, is sometimes associated with ectopia vesicae. In severe cases an 
attempt should be made to remedy this congenital defect by a plastic 
operation. 

Hypospadias is of more frequent occurrence than the former defect. 
The orifice is usually situated at the base of the glans, and in severe cases 
is joined by a deep fissure which divides the scrotum in the middle line, 



LOCALIZED AND MINOR AILMENTS 



493 



forming labia, as in the female. In this event it is likely to be mistaken 
for hermaphroditism, a maldevelopment characterized by the coexistence 
of fully developed ovaries and testicles in one individual. A plastic opera- 
tion has been devised for hypospadias. 

Balanitis. — Inflammation of the glans penis may be caused by lack of 
cleanliness, purulent discharges from the urethral canal, specific ulcers, and 
the like. By attention to the cause, cleanliness, and the use of antiseptic 
dusting powders the inflammation may generally be made to subside within 
a short time. 

Paraphimosis, or constriction of the prepuce behind the glans, gives 
rise to oedema and cyanosis, and if not soon relieved, to gangrene. In early 
cases reduction may be effected by drawing the foreskin forward while 
pressure is exerted simultaneously upon the glans. In cases of long standing 
reduction should be preceded by division of the constricting band. 

Phimosis. — Stenosis of the preputial orifice, if left untreated, is very 
likely to give rise to balanitis, paraphimosis, and a number of reflex nervous 
irritations, such as enuresis, etc. Hence the advisability of early treatment. 
In quite a number of cases this condition may be successfully remedied by 
dividing the stenosed border by a few small longitudinal incisions and by 
retraction of the prepuce. In severe cases, however, circumcision must be 
resorted to (see Paediatrics). 

Herpes pragputialis is a vesicular eruption of the penis which may ter- 
minate as a simple ulcer, and which is apt to be mistaken for the initial 
lesion of syphilis. It generally disappears rapidly under treatment with 
sedative lotions or dusting powders as does eczema of the prepuce. 

Benign tumors, such as cysts, fibromas, etc., are sometimes observed on 
the glans and prepuce. The treatment is the same as for tumors affecting 
other portions of the body. 

Priapism is a term used when the penis is in a chronic state of erection 
from central nervous disease. 

Chordee is a painful erection with curvature from various transitory 
causes. 

Urethra 

Diverticula of the male urethra are rare. 

Stenosis of the urethral orifice is readily enlarged by cutting under 
cocaine. 

Stricture, or narrowing, of the urethral canal is of quite frequent occur- 
rence and the cause of numerous ailments of the genitourinary tract. In 
the great majority of instances stricture is the result of specific urethritis, 
although traumatism and an unhealthy condition of the urine are occasion- 
ally the causes of the development of stricture. The most frequent situation 
of the stricture is in the neighborhood of the triangular ligament . 

Symptoms of Stricture. — Increased frequency of urination, gradual 
reduction in the size of the stream, dribbling from the urethra, and "in- 
continence from retention." In cases of long standing there are symptoms 
of cystitis and later involvement of the ureters and kidneys. 

Treatment. — Slight strictures of recent development frequently yield 
to the treatment with astringent injections, warm baths, ichthyol crayons, 



494 



THE GENITOURINARY SYSTEM 



alkaline diuretics with belladonna or hyoscyamus, etc. These remedies 
should always be employed in cases of "spasmodic" stricture, a reflex 
contraction of the muscular fibres of the urethra, which is apt to be mistaken 
for organic stricture. Cases of long standing which fail to improve under 
the simple measures just outlined require operative interference. The 
mechanical means to be resorted to are gradual dilatation, continuous 
dilatation, dilatation by means of expanding instruments, internal incision, 
and division from the perinseum. 

Urethral caruncles at the orifice sometimes give rise to reflex symptoms 
which disappear when the excrescences are cauterized or cut away. 

Papillomata and polyps of the urethra give rise to reflex symptoms 
and discharges. They may be located by means of Klotz's urethroscope 
and cauterized or removed by the snare or knife. 

Urethral Calculus. — A small stone may become impacted in any part 
of the urethra and give rise to pain or also to retention of urine when the 
stone is large enough to obstruct the urinary canal. 

Treatment. — If far forward, the stone may often be removed by gentle 
manipulation or the urethral forceps; otherwise operative interference must 
be resorted to in cases in which the obstruction is very pronounced. 

Periurethral abscesses are occasionally met with. They give rise to local 
disturbance and the so called urethral chill, and require the knife. 

Simple non-venereal urethritis from local irritation or irritating food and 
drink or from gouty diathesis yields to cleanliness and general hygienic 
management. 

Prostate 

Prostatism without enlargement of the prostate is due to a contracture 
at the neck of the bladder of fibrous and inflammatory origin, probably 
gonorrhceal, owing to which an obstruction to the outflow of urine is offered. 

Treatment. — Galvano-caustic incision of the indurated neck of the 
bladder offers the best chances of cure in severe cases. 

Enlargement of the Prostate. — Men advanced in years usually suffer 
from more or less disturbance of the prostate. Gradual hypertrophy is 
the most frequent affection. One or more lobes may become enlarged, and 
the symptoms vary according to the extent of the enlargement. The chief 
characteristic of this disease is impediment to emptying the bladder, residual 
urine, marked strangury, and not infrequently severe pain; soon symptoms 
of cystitis supervene and the urine shows the presence of pus and blood. 

The diagnosis is made positive by rectal digital examination. 

As the causation of this affection is not thoroughly understood, the 
treatment must necessarily be symptomatic. An endeavor should be made 
to relieve the symptoms by hot sitz baths, hot water injections, irriga- 
tion of the bladder, alkaline diuretics and hyoscyamus internally, and 
morphine, belladonna, and ichthyol in the form of suppositories. Opera- 
tive interference is the last resort and gives very good results in many cases. 

Acute Prostatitis. — Inflammation of the prostate may be either acute 
or chronic. 

The causes of acute prostatitis are chiefly specific urethritis, trauma- 
tism, and occasionally infectious diseases. The onset is usually sudden, 



PROSTATE, TESTICLES AND SPERMATIC CORD 



495 



with increased frequency of micturition, a sensation of heat and weight in 
the perineal region, often pain during micturition and defalcation, and, if 
long continued, also more or less constitutional symptoms. The latter is 
particularly the case if the inflammation is very pronounced and an 
abscess forms. 

Treatment. — Rest in bed with the hips elevated, leeches to the peri- 
naeum, ichthyol and opium suppositories, and catheterism if the patient is 
unable to pass his urine naturally. Should pus form, the abscess should be 
incised and drained. 

Chronic prostatitis may arise as a result either of the acute variety or 
of excessive sexual excitement, urethral stricture, haemorrhoids, and vesical 
calculus. The symptoms generally set in slowly. There are dull pains, 
increased frequency of urination, partial impotence, and a periodic dis- 
charge of a mucoid or mucopurulent fluid from the urethra. The treat- 
ment of this condition is practically the same as that of the acute variety, 
plus removal of the cause. Massage of the prostate is alleged to be a very 
efficient remedy in this condition, but local treatment must not be pro- 
longed over an undue period. 

The seminal vesicles may be the seat of inflammation or stone. Stripping 
of the vesicles with the finger in the rectum is of value whenever active 
massage of the parts is indicated. Undue and prolonged or frequent 
stripping is harmful. 



Anorchidism and polyorchidism are rare. 

Cryptorchidism (undescended testicle), sometimes mistaken for hernia, 
is very frequently observed in infancy. The testicle remains in the ab- 
dominal cavity or may be found at any point in the inguinal canal. Descent 
usually takes place spontaneously, and the abnormity requires no interfer- 
ence unless the testicle has made for itself a false passage or gives rise to 
much pain and tenderness. 

Orchitis and Epididymitis. — Inflammation of the testicle or epididymis 
may be due to gonorrhoea, traumatism, or impaction of a calculus. Orchitis 
is sometimes a complication of parotitis. There is pain in the testicle and 
along the spermatic cord. If the epididymis only is involved, the swelling 
is limited to the lower and posterior portion of the testicle; otherwise the 
entire testicle and scrotum are cedematous and very painful to the touch, 
with occasionally constitutional symptoms. 

Treatment. — Rest in bed, hot fomentations, and anodynes for the 
relief of pain; later a suspensory bandage and the following local appli- 
cation: 



Testicles and Spermatic Cord 



~Bf Eng. hydrarg., . . 

Lanolini 

Ichthyol 

Ext. belladonna?. 



5ij: 
oyj; 
oj; 



gr. x. 



M. S. : Apply externally twice daily. 



In the event of pus formation an incision is necessary. 



496 



THE GENITOURINARY SYSTEM 



Varicocele, or a dilated and varicose condition of the spermatic veins, 
is more common on the left side. The aetiology of this condition is not quite 
clear. It is generally observed in people whose occupation involves pro- 
tracted standing. The diagnosis is readily made by inspection and palpa- 
tion, the veins presenting a soft, irregular, opaque, knotted, pyriform mass. 
There may be a sensation of dragging or severe pain. 

Treatment. — A suspensory bandage, general tonic treatment, and at- 
tention to the bowels. In severe and protracted cases, radical cure by 
means of subcutaneous ligature. 

Hydrocele is an accumulation of serum in the tunica vaginalis testis. 
The fluid may be contained in the tunica vaginalis proper — vaginal hydro- 
cele — and this is further spoken of as congenital when the tunica vaginalis 
preserves its communication with the general peritoneal cavity; again, 
the fluid may be contained in a cyst in connection with the spermatic cord, 
when it is spoken of as encysted hydrocele of the spermatic cord. The diag- 
nostic signs are translucency, fluctuation, absence of impulse on coughing, 
and absence of pain. 

Treatment. — Puncture of the swelling with a trocar and cannula, with 
or without the injection of a stimulating fluid (e. g., tincture of iodine or 
carbolic acid). A radical operation is often necessary for a cure. (See 
also Dropsy.) 

Hematocele is an extravasation of blood in the tunica vaginalis. It is 
most frequently caused by injury to the scrotum. It resembles hydrocele 
in shape, but it differs from it by its sudden appearance, absence of trans- 
lucency, and the presence of pain and ecchymosis. 

Treatment. — An ice bag and cold lotions externally and rest in the 
recumbent posture; if an abscess forms, free incision and drainage. 

Wounds and gangrene of the testicle necessitate prompt surgical treat- 
ment. 

Neuroses and neuralgias of the male generative organs are very common 
in neurotic individuals. In the absence of some source of local irritation 
about the anus and genital region, a general tonic treatment is indicated, 
including outdoor exercise, regulation of the bowels, cold douching, iron, 
bromides, etc. 

Skin manifestations of the male generative organs, such as lymphatic 
varix, intertrigo, eczema, pruritus, erysipelas, oedema, and gangrene, and the 
occurrence and treatment of inguinal lymphadenitis are discussed in other 
chapters. 

Benign and malignant tumors, syphilis, tuberculosis, stone, and parasites 
of the male generative organs are discussed in a previous chapter. 



CHAPTER XVIII 



THE GENITOURINARY SYSTEM— Continued 

VENEREAL DISEASE IN THE MALE AND FEMALE AND 
DERANGEMENTS OF THE SEXUAL FUNCTION IN THE 
MALE 

Synopsis: Syphilis, Chancroid, Gonorrhoea. — Prevention of Venereal Disease. — Derange- 
ments of the Sexual Function in the Male. — Priapism, Masturbation, Pollution, Im- 
potence, Sterility of the Male or through the Male. 

INTRODUCTORY REMARKS 

The sexual appetite is a natural instinct in all healthy individuals. Its 
gratification, especially by illicit sexual intercourse, is often followed by dis- 
astrous results to the individual in the shape of annoying and dangerous 
disease transmitted at the time of the sexual act. Chancroid infection 
remains local and runs the course of an acute ailment with no important 
sequelae. 

Gonorrhoea, which is looked upon as a trivial accident in sexual life by 
the laity, is in reality a severe infection, with far reaching sequelae for the 
male and female, and particularly for the innocent married woman, whose 
pelvic organs so readily become infected from a latent gonorrhoea of the 
husband, this giving rise to untold suffering and often necessitating severe 
operative interference. 

Syphilis, with its chronicity and sequelae, is the cause of much of the misery 
which the physician encounters all the year round. Although venereal 
disease may be innocently acquired, such ailments are almost always spread 
through the agency of male profligates and female prostitutes. On ethical 
grounds, it may not be correct to license an evil like prostitution, but unless 
we take the ground that the dangers of extramarital sexual intercourse, 
like the dangers of alcoholic indulgence, are character builders, weeding out 
the unfit and timid who shirk the responsibilities of marriage, it will be 
well to protect the ignorant, the careless, and the innocent by restricting the 
spread of venereal disease, as we do in the case of other communicable 
diseases. To this end, the control of the social evil should be taken out 
of the hands of the police and placed in the keeping of a sanitary or hygienic 
board or body, whose duty it would be to formulate and carry out humane, 
practical restrictions in lieu of the brutal and cowardly methods now in vogue 
against the unfortunate fallen woman who is more the product of man's 
unjust social laws, than naturally depraved. Prostitutes must be segregated, 
frequently examined, and, if disease has developed, isolated and given 

497 



498 



THE GENITOURINARY SYSTEM 



medical care, as in other instances of communicable disease. It should be 
the duty of physicians to instruct young men of their clientele and their 
parents as to the dangers of prostitution and as to the safety of marriage 
in this respect. This campaign of education should be extended to high 
schools and colleges for young men. 

Men and women suffering from venereal disease and knowingly infecting 
others must be punished by law. 

SYPHILIS IN ADULTS AND CHILDREN 

Syphilis is an infectious disease, the microorganism of which is as yet 
unknown. It has a distinct period of incubation with a train of systemic 
disturbances, like all other eruptive fevers. It is in a measure self-limited 
and confers immunity. It is influenced by specific treatment. It may 
run a benign or semimalignant course. 

As the ordinary mode of transmitting syphilis is by sexual intercourse, 
the usual portal of entrance is the genital apparatus; but as other modes 
of infection by accidental contact are not infrequent, the initial lesion is 
occasionally encountered elsewhere. Syphilis may be looked for under 
any circumstance of life; no one is absolutely secure against the possible 
acquisition of this disease. It is not infrequently contracted in surgical 
and midwifery practice. The initial lesion, or syphilitic chancre, cannot 
in its first stages be distinguished from herpes, simple or chancroidal ex- 
coriations, etc. The mature indurated chancre is sufficiently characteristic 
in appearance to make the diagnosis. It is a circumscribed hardness, of 
about the form of a split pea, not painful. It is stationary for a time and 
then disappears, but usually leaves an induration. Extragenital chancres 
and chancroids situated in the vagina or on the cervix uteri are readily 
overlooked. 

After the chancre has been in existence for about six weeks or more, 
and a swelling of the neighboring lymph nodes has taken place, a skin erup- 
tion makes its appearance, which is macular, papular, or pustular in char- 
acter. About this time a general feeling of malaise is experienced, together 
with an irregular fever temperature and throat symptoms (mucous patches). 
The eruption may vary in appearance from roseolar spots or measleslike 
spots to pustules similar to those of smallpox, but showing no typical ura- 
bilication. Occasionally a confluent pustular eruption presents itself in 
larger patches with deep ulceration and scab formation (rupia syphilitica). 

Tertiary Manifestations. — Whereas the secondary manifestations are of 
an acute character and are more or less confined to the lymph nodes, skin, 
and throat, the tertiary phenomena, which come on after several years, 
show a marked chronicity or tendency to relapse, and may be present in 
any organ or tissue of the body in a multitude of shapes, such as granulation 
tumors, scaly skin eruptions, amyloid degeneration, etc. A syphilitic 
endarteritis may be manifest in the brain and spinal cord, in the viscera, 
including the eye, in bones and muscles, and result in the most formidable 
organic changes in the various organs and tissues. 

Such is the typical course of syphilis; but there are many variations in 
the course of the disease in various individuals, depending upon the intensity 



SYPHILIS IN ADULTS AND CHILDREN 



499 



of the infection and the natural resistance of the body as influenced by- 
constitution, habits of life, and, above all, judicious treatment. Syphilis 
may imitate almost any other disease. 

Syphilis of the mouth and throat, of the liver, of the gastroenteric tract, 
of the circulatory system, of the urinary tract, and of the brain and spinal 
cord is described under the various headings. 

Prophylaxis. — Personal prophylaxis consists in continence, or personal 
purity, or the wearing of a condom. The proper attitude of the State 
toward venereal disease should be the same as toward any other commu- 
nicable ailment. Marriage should not be contracted until two full years 
have elapsed after the date of infection, during which time prolonged and 
thorough treatment must be carried out. 

Instructions to Those Suffering from Syphilis. — Syphilis is a constitu- 
tional disease. It is "in the blood." Local remedies and taking medicine 
for a few months will not cure you. You must be treated for two to three 
years. The effects of this disease are far reaching, and if treatment is 
neglected, much trouble and suffering may be caused, not only to yourself, 
but to others. The following rules must be observed during the first 
year: 1. Sexual intercourse should not be indulged in. 2. Sleep alone. 
3. Under no circumstances should any one be allowed to use your toilet 
articles, such as towels, brushes, combs, razors, shaving brushes, etc. 4. No 
article that has been in your mouth should be used by others, such as 
tooth brushes, tooth picks, pencils, pipes, cigars, cigarettes, forks, spoons, 
drinking cups, etc. 5. You must not kiss any one. 6. Brush your teeth 
night and morning and keep your mouth clean. 7. If you have bad teeth, 
have them attended to by a dentist, and be sure to tell him that you have 
syphilis, so that he can take necessary precautions and avoid the pos- 
sibility of infecting others (Dr. Cabot). 

Treatment should be given as soon as a positive diagnosis has been made. 
In mercury and potassium iodide we have the specific medication for 
syphilis. Inunction cure : One drachm of mercurial ointment, containing 
some lanolin, is rubbed into the skin over various parts of the body once a 
day for six days. A warm bath is taken on the seventh day, and on the 
eighth day the mercurial inunctions are resumed. This is continued until 
thirty courses of inunctions have been given. Subsequently mercuric 
biniodide or protiodide, gr. J, may be given three times a day for weeks 
or until salivation is produced. During the administration of mercury the 
mouth must be kept scrupulously clean and a mouth wash and gargle of 
potassium chlorate should be frequently used. Biniodide of mercury may 
be given combined with potassium iodide, and bichloride of mercury with 
sodium chloride. 

Injections of gtt. xv of the following mixture, deep into the buttocks, 
under antiseptic precautions is another good form of treatment. 



Hydrarg. salicyl., 

01. olivse, 

Lanolin., 



gr. xxi] ; 

5h>s.; 

3ss. 



M. S.: Inject every five, six, or seven days. 



500 



THE GENITOURINARY SYSTEM 



Hydrarg. chlor. cor., gr. xv to xxx; 

Aquae, •. 5jv; 

Sodii chlorid., 3j to 3jss. 

M. S. : Inject 20 drops every other day into the gluteal region. 



The use of mercury must be suspended if salivation appears. In ad- 
dition to the specific treatment, the general condition should be kept at par 
or improved by means of warm baths, physical exercise, liberal diet, and 
avoidance of overfatigue and worry. 

A sea voyage is beneficial or a sojourn in the mountains. After the 
lapse of six months the patient should present himself for a second course 
of treatment of a milder nature. A third course is advisable in the second 
year. The manifestations of syphilis on the skin and mucosa require but 
little local management when the constitutional treatment is energetic. 

The tertiary manifestations of syphilis are amenable to treatment with 
potassium iodide and a tonic regimen. 

In the present state of our knowledge the curability of syphilis cannot 
be denied, particularly when we observe reinfection after an alleged cure. 
On the other hand, it is a well known fact that syphilitic degeneration of 
vital organs may threaten and destroy life after years of apparent cure and 
freedom from symptoms. It is quite important to examine the blood of 
syphilitics and to stop the mercurial treatment and institute a tonic regimen 
when secondary amemia is detected. 



Hereditary Syphilis; Congenital Syphilis; Syphilis Hereditaria Tarda 

Inherited syphilis may be due to maternal or paternal infection. A 
syphilitic father may beget a healthy child, and a mother who has borne a 
syphilitic child may be herself immune. The mother may be infected after 
conception and may bear a healthy or syphilitic child. 

The acquired form is rare in infants. Infection may take place through 
kissing, from a wet nurse, and by other accidental contact, or may be con- 
veyed in the rite of circumcision. The symptoms and treatment are the same 
as in adults; the dose of drugs to be employed is 5V of that for adults. 

The Congenital Form of Syphilis in Infants. — Many syphilitic children 
are still-born or die soon after birth. The more severe lesions are found in 
the bones, liver, spleen, and mucous membrane of the respiratory tract 
and the mouth. The changes in the liver are interstitial and gummatous, 
and due to endarteritis as in other organs and viscera. Syphilitic bron- 
chostenosis is occasionally observed. The skin lesions in congenital syphi- 
lis are usually of a coppery hue and resemble those of measles. The 
mouth may show brownish scaly patches and the palms and soles may des- 
quamate. Soft, flat papules are also observed, and when located about the 
anus and genitals they are called condylomata lata, the glairy secretion of 
which is very contagious. Bullous eruptions are not uncommon (pemphi- 
gus syphiliticus). Other syphilitic changes in childhood are the notched 
Hutchinson's teeth, a hazy ground glass appearance of the cornea, osteo- 
chondritis, and periostitis (syphilitic dactylitis). Syphilitic children have a 



CHANCROID; SOFT CHANCRE; ULCUS MOLLE 



501 



sallow, cafe au lait skin. Their cry is hoarse and accompanied by snuffles. 
Mucous patches and stomatitis are frequently observed. 

Late manifestations of congenital syphilis (syphilis hereditaria tarda) 
are found as gummatous changes in the skin and viscera, and the liver may 
become cirrhotic. Children of syphilitic parentage are generally anaemic 
and liable to become rhachitic, and they are subject to catarrh of the respira- 
tory tract. When exposed to diphtheritic infection, they are apt to contract 
membranous croup. 

Prophylaxis and Treatment. — Procreation should not be allowed until 
after two or three years of active treatment. A pregnant mother with 
active syphilis should have energetic treatment. A child of luetic parent- 
age should not be wet nursed even in the absence of mucous patches in the 
mouth, and great care must be exercised in the management of nursing 
bottles and nipples. The best treatment, in the experience of the writer, 
is the inunction treatment with mercurial ointment reduced one half. 
Twenty grains are rubbed into the skin of the abdomen and loins once a 
day for a week, this to be repeated after a week's intermission, and again 
if necessary. Calomel, gr. T 1 „, or gray powder, gr. \, may also be given 
three times a day. Iodide of potassium is not adapted to this class of cases. 
The greatest care must be given to the nutrition and general health. Later 
in the disease syrup of iodide of iron is indicated. 

CHANCROID; SOFT CHANCRE; ULCUS MOLLE 

Chancroid is a contagious venereal ulcer sometimes presenting as a 
pimple or excoriation. The severe form is the phagedenic ulcer, which 
may end in sloughing and gangrene of the affected part. Chancroid may 
be situated anywhere on the prepuce, glans, or labia, or vagina, or within 
the anterior urethra. It is soft to the touch, but from frequent irritation 
and cauterization it may become hard and indurated, simulating the primary 
lesion or induration of syphilis. In urethral chancroid a sanguineous 
discharge appears at the orifice, and on taking the penis between the fingers 
a circumscribed indurated and tender spot can be felt. Chancroid is a 
local affection. To distinguish between a simple and chancroidal excoria- 
tion is often difficult and occasionally impossible. A syphilitic chancre 
has a cartilaginous hardness and is followed by chronic induration of the 
inguinal glands (bubo). Glandular induration from chancroid frequently 
ends in suppuration (soft bubo). 

The phagedenic and sloughing chancre cannot be mistaken for the 
syphilitic variety. 

The prognosis is favorable, and it takes from one to six weeks to effect 
a cure. 

Prophylaxis is secured by personal purity or the wearing of a condom. 

Treatment. — An excoriation or ulcer may be cauterized with pure nitric 
acid and dressed with yellow oxide of mercury ointment, gr. viij to §j. 
Should chancrous pus discharge from under a tightened prepuce, the latter 
must be slit open and all tension removed and the ulcer treated in the usual 
way. When local inflammation and swelling are pronounced, ice cold 
lead water should be applied to the parts. 



502 



THE GENITOURINARY SYSTEM 



A penis with a sloughing chancre should be bathed every two hours in 
warm water containing liquor sods chlorinate, 1 to 20. The promptest 
means of arresting sloughing and haemorrhage is the actual cautery with an 
occasional incision to relieve tension. The patient should have fresh air, 
a generous diet, and open bowels, and 5 gtt. of dilute hydrochloric acid in 
water should be taken after eating, to aid digestion. Alcohol in some form 
may occasionally be useful for its stimulating properties. 

A bubo requires an ice bag or hot water bag, and should suppuration 
set in free incision or extirpation. 

Chancroid in the female is treated in the same way. Sitz baths are very 
serviceable, after which the labia are to be kept apart by means of lint 
smeared with yellow mercury ointment. 

Chancroids of the lip, tongue, and other parts are treated in the same way. 

GONORRHOEA IN THE MALE AND FEMALE, ADULT AND CHILD, WITH 
REMARKS ON ITS COMPLICATIONS AND SEQUELAE 

Gonorrhoea is a contagious mucopurulent urethritis caused by a specific 
germ, the gonococcus of Neisser. For the technique of its demonstration, 
see the chapter on Laboratory Diagnosis. 

When the disease is confined to that portion of the male urethra situated 
in front of the compressor muscle, we speak of anterior urethritis. When the 
membranous and prostatic portions are affected, we speak of posterior 
urethritis. If a patient passes his urine into two glasses, that in the first 
glass will be cloudy, and that in the second glass clear if the bladder and 
posterior urethra are free. 

Symptoms and Course of Gonorrhoea, or " Clap." — A red meatus with a 
scanty discharge is the first symptom. The discharge becomes thick, 
purulent, and greenish. The foreskin becomes swollen and cedematous. 
A burning or scalding sensation on urinating is complained of. Occasionally 
painful erections (chordee) occur. In favorable cases the discharge grad- 
ually disappears after the fourth week, but in many instances acute exacer- 
bations or relapses occur, generally and erroneously attributed to some 
indiscretion in eating or drinking. 

In acute posterior urethritis there is considerable pain and vesical tenes- 
mus, with a marked and sudden decrease in the discharge and increased 
desire to micturate. Chordee and nocturnal pollutions are common, and 
the two glass urine test shows that all the urine is cloudy, because some of 
the secretions are apt to pass backward and settle at the base of the bladder. 

Prophylaxis. — It is quite feasible for both sexes to remain continent 
until marriage. When extramarital sexual intercourse is indulged in, the 
safest plan is to wear a condom or to thoroughly wash the genitals after 
coition -and inject a few drops of a 20 per cent protargol solution in glycerin, 
after first urinating. 

Instructions to Those Having Gonorrhoea, or "Clap." — Gonorrhoea, or 
" clap," is a local contagious disease. To avoid infecting others and to pre- 
vent complications, a bubo, stricture, swollen testicles, etc., the following 
rules should be observed: 1. During the first few weeks walking should 
be limited. When the discharge is profuse you should keep off your feet 



GONORRHOEA IN THE MALE AND FEMALE, ADULT AND CHILD 503 



as much as possible. 2. Do not use alcohol in any form, as it always 
prolongs the disease. Drink milk, tea, Vichy, or Seltzer, and from six to 
eight glasses of water during the day. 3. Avoid all sexual relations until 
you have been pronounced cured by your physician, as the disease may be 
given to a woman even after the discharge has apparently ceased. When 
it is present you should avoid sexual excitement, as erections always 
aggravate the disease. 4. Always wash the hands after handling the 
parts. The discharge, if carried to the eyes, will cause blindness. 5. Sleep 
alone, and be sure that no one uses any of your toilet articles, particularly 
towels and wash cloths. 6. Never lend your syringe to any one, and as soon 
as you are well destroy it. 7. Be sure that the bowels move every day. 
If they are inclined to be constipated, take a dose of Rochelle salts before 
breakfast. 8. Do not use mustard, pepper, horseradish, or stimulating 
sauces on your food. (Cabot.) 

Treatment. — Abortive local treatment by irrigation at the onset of 
the trouble is highly recommended by some able specialists under the 
supposition that the gonococcus can be destroyed directly or destroyed and 
washed away as it reaches the surface from the deeper layers of the 
urethra. The writer's clinical experience is in accord with that of those 
genitourinary specialists who believe in the postponement of local treat- 
ment until after the acute stage has subsided, because the patient does 
not seek advice until the evidence of inflammation is present. In the 
mean time the patient is told to live according to the instructions given 
above, and ordered to take an emulsion or capsules of copaiba several 
times a day and drink freely of warm or cold peppermint tea or Vichy water. 

After from four to six weeks of such expectant treatment one or more 
of the following injections may be employed for the "morning drop": 



1 to 500, in water; 



Acetate of lead, 

Sulphate of zinc, 

Sulphocarbolate of zinc, 

Alum, 

Tannin, 

Nitrate of silver, 1 to 1,000; 

Cupric sulphate gr. v to §jv; 

Potassium permanganate, 1 to 2,000; 

Ichthyol, 2 per cent; 

Protargol, 1 per cent. 



Injections are made with a blunt syringe after urinating and after 
cleansing the meatus. The injection fluid may be retained for some minutes 
by compressing the urethral orifice. Urethral suppositories of gelatin or 
cacao butter, containing opium, belladonna, and the various astringents, are 
serviceable. The penis may be bathed frequently in lukewarm antiseptic 
water. 

The so called abortive treatment: The anterior urethra is washed with 
warm water in order to remove the accumulated discharge; an ordinary 
hand syringe is used for the purpose. Then 2 drachms of a 20 per cent solu- 
tion of argyrol are injected into the anterior urethra and held there for ten 
33 



504 



THE GENITOURINARY SYSTEM 



minutes; the patient is then given a 20 per cent solution for use at home 
and the injection, as described above, is repeated every three hours night and 
day for two or three days; the patient reports at the office once daily for 
observation. This treatment is a troublesome one and expensive. 

Chronic anteroposterior urethritis (gleet) is due to a more severe and 
deep seated inflammatory localization of the malady in one or more parts 
of the urethra. 

Symptoms. — Shreds in the urine, a mucoid discharge, gluing together 
of the urethral orifice, a feeling of weight or pain in the perinseum and 




Fig. 156. — Urethral Hand Syringe, Holding One-quarter Drachm. 

testicles, increased frequency of micturition, and nocturnal and painful 
pollutions. Such symptoms are increased by alcoholic stimulation and 
sexual indulgence. The patient is apt to become neurasthenic and fall a 
prey to the charlatan, and frequently by his incessant complaints drives 
the best of physicians into all kinds of harmful local treatment. 

Treatment. — The patient should take moderate exercise in the open 
air and must be made to understand that he will be cured. Tonics, such 
as iron and arsenic, and cool sponge baths are indicated. The afore- 
mentioned astringent injections and urethral suppositories may be em- 
ployed. Another plan is to irrigate with a warm saturated solution of boric 




Fig. 157. — Urethroscope (Klotz). 



acid every two or three days, after which an applicator wrapped with cotton 
saturated in a 20 per cent argyrol solution is passed into the urethra and 
moved very gently to and fro, much in the same manner as local applica- 
tions are made to the nasopharynx. The patient is given a 5 per cent 
solution for injection three times daily, or we carefully dilate the urethra 
with lubricated steel sounds several times at intervals of two or three days. 

When a local examination by means of the Klotz endoscope reveals 
granulations or ulcers, direct cauterization with a cotton carrier bearing a 
2 per cent argentic nitrate solution is indicated. 

If during the course of the disease the bladder has become infected, 



FUNCTIONAL DERANGEMENTS IN THE MALE 



505 



as shown by the condition of the urine and by urgent bladder symptoms, 
urotropin, in 10 grain doses, may be given three times a day. Irrigation 
of the bladder should not be practised, except in very urgent cases (see 
Cystitis). 

The complications and sequelae of acute anterior clap are phimosis, 
paraphimosis, chordee, balanitis, adenitis, and periurethral abscess. 

The complications of posterior urethritis are infection of the prostate, 
seminal vesicles, spermatic cord, testicles, bladder, kidneys, and peri- 
tonaeum, or stricture, gonorrhceal rheumatism, sexual neurasthenia, and 
sterility. 

In the practice of paederasty the rectum may become infected, resulting 
in ulceration and stricture, and gonorrhoea of the mouth has been observed. 

Venereal Disease in the Female 

Chancroid and syphilis in the female does not differ from that of the 
male except as regards location, and treatment is practically the same as in 
the male. 

Gonorrhace in the female is dangerous on account of its sequela?. It 
usually shows itself as vulvovaginitis with a sense of burning and fulness of 
the parts. The gonococcus is found in the purulent discharge. 

Treatment. — Vaginal douches of warm borax water, 5j to 1 pint, or 
bichloride of mercury, 1 to 5,000, or sulphocarbolate of zinc, 3ij to 1 quart, 
are to be employed three or four times a day, also warm sitz baths. After 
the acute symptoms have subsided, the vagina should be swabbed once a 
day with a 2 per cent nitrate of silver solution. 

Complications, residual symptoms, and sequelae in females are endome- 
tritis, tuboovarian disease, cystitis, pyelonephritis, gonorrhoea of the rec- 
tum or eye, periurethral and Cowper's gland abscess, granular vaginitis, and 
sterility. 

In conclusion, it must be emphasized that an apparently fresh outbreak 
of gonorrhoea is no proof of a new infection ; it is usually a manifestation of an 
old but latent infection. 

For gonorrhoea in children, see Paediatrics. 

FUNCTIONAL DERANGEMENTS IN THE MALE 

Sexual Erethism; Masturbation; Pollution 

Priapism is of two kinds, one unattended by sexual desire and the other 
a sexual erethism of the psychical type. The former may be due to a variety 
of causes, such as reflex irritation from an irritable prostate, haemorrhoids, 
stone in the bladder, phimosis, or central nervous disease of an organic 
nature. By removing the cause, if it is possible to do so, we overcome the 
trouble. Camphor, hyoscyamus, lupulus, and the bromides are indicated. 
Reflex priapism is observed after operations on the penis, and may be so 
urgent as to tear open sutures. 

Sexual erethism of the psychical type is usually cured by cold sponging 
and bromides and bitter tonics. 



506 



THE GENITOURINARY SYSTEM 



Masturbation is practised by most boys, and thigh friction is nothing 
unusual in infants and children. Masturbation and sexual excess may 
result in a hypera:mic state of the sexual organs and finally lead to sexual 
neurasthenia. 

In the treatment of such cases it is important that the physician gain 
the confidence of the patient and impress upon his mind that masturbation 
is injurious only while it is practised, and that health will return when the 
habit is stopped. Cold sponge baths, bromides, and tonics are indicated. 
The bowels must be made to move freely. 

Pollutions may take place during the day or at night, in sleep. Natural 
emissions may take place once a week without discomfort or injury. Too 
many pollutions from the fondling of women may lead to local hyperemia 
and subsequent neurasthenia. 

In such cases all exciting practices must be stopped, and if marriage is 
not possible, the company of women should be avoided. Emissions may 
be a sign of neurasthenia and general debility or of local disease. 

Treatment is directed to the underlying cause. The general manage- 
ment is that of Erethism. 

Sexual degenerates and perverts deserve our pity and contempt. The 
management of the various phenomena of degeneracy is not within the scope 
of this book. 

Impotence and Sterility of the Male. — Functional impotence and sterility 
may be due to senile degenerative changes, but there is no definite period 
at which such changes occur; some men are sterile at fifty and in some the 
impregnating power remains to old age. 

Functional impotence may depend upon mental non-development or 
upon grave disease of the central nervous system, in which event the prog- 
nosis is bad. It is, however, more frequently a neurosis, depending upon 
the mental state of the individual (bashfulness, anxiety, fear, disgust), 
or it is due to malnutrition or cachexia and anaemia from chronic ailments. 

Aspermatism means absence of seminal fluid, which is mostly due to 
disease of the seminal vesicles and disappears when the vesicles resume 
their function. 

Azoospermatism is the absence of spermatozoa in the ejaculated semen. 
In such cases spermatozoa may not be formed in the testicle or may not 
reach the seminal vesicles on account of obstruction. Azoospermatism does 
not interfere in the performance of the sexual act. 

Prostatorrhosa is often mistaken for spermatorrhoea (spermatophobia) . 

The prognosis of functional impotence depends entirely upon the under- 
lying cause. When a grave nervous lesion can be excluded in middle 
aged or younger men, a hopeful prognosis is indicated and demanded in 
order to restore self-reliance. 

Treatment. — The general principles of the treatment of impotence in 
ansemic and neurotic individuals may be laid down as follows: Freedom 
from mental care, regular physical activity, outdoor life, regular habits, 
no tobacco or alcohol excess, a liberal, highly nutritious diet, cool and cold 
sponge baths, regular sexual approach from the opposite sex, no premature 
withdrawal, and removal of fear of pollution. 

The following drugs may be taken: Iron, arsenic, strychnine, phosphorus, 



FUNCTIONAL DERANGEMENTS IN THE MALI] 



507 



cantharides, and potassium iodide. Electricity and vibratory massage 
should be employed. 

In cases of functional impotence in the newly married, the hymen 
should be ruptured by the finger. Functional impotence, it is maintained, 
yields frequently to the subcutaneous administration of johimbin (Spiegel) 
in a 2 per cent watery solution. The initial dose is from 10 to 15 drops, 
daily or every other day, until twenty injections have been taken. 

Sterile Marriages. — Gonorrhceal urethritis is the most frequent cause 
of sterility. It is stated that about 70 per cent of sterile marriages must be 
attributed to the husband, either from azoospermia or impotence, or owing 
to the wife being infected with gonorrhceal disease by her male partner or 
partners. Noeggerath maintained that 90 per cent of sterile women were 
married to husbands who had suffered from gonorrhoea previous to or during 
marital life and that many of them had latent specific urethritis. 

Syphilis also produces sterile marriages and is a frequent cause of 
abortion. In sterility due to specific urethritis or syphilis and its sequelae 
the treatment of the underlying cause is the primary consideration. 



CHAPTER XIX 



THE GENITOURINARY SYSTEM — Concluded 

GYNAECOLOGICAL MEMORANDA 

Synopsis - . Diagnostic Palpation, Examination with Specula, Examination of Discharges and 
Scrapings in the Laboratory. — Menstrual and Functional Disorders and Neuroses. — Con- 
stipation in Females (see Constipation) . — Late Menstruation in Girls. — Amenorrhcea. — 
Dysmenorrhcea. — Menstrual Colic. — Intermenstrual Pain. — Iliolumbar Neuralgia. — 
Menorrhagia. — Metrorrhagia. — Vicarious Menstruation. — Menopause. — Sterility in the 
Female. — Incontinence of Urine in Females. — Vaginismus, Nymphomania, Masturba- 
tion. — Vulvovaginal Discharges. — Leucorrhcea, Purulent Vulvovaginitis, Gonorrhceal 
Vulvovaginitis, from Endometritis, from Granular Cervix, from Cancer. — Inflammation 
of the Vulvovaginal Glands, Abscess. — Flexions, Versions, Prolapse. — Treatment by 
Binder, Pessary, Operation. — Laceration of Perinmum and Cervix. — Treatment by 
Primary and Secondary Operation. — Fistula, Vaginovesical, Rectovaginal. — Extra- 
uterine Pregnancy. — Internal Bleeding. — Haematoma, Hematocele.— Pelvic Inflam- 
mation and Suppuration. — Palliative and Operative Treatment. — Benign and 
Malignant New Growths. — Abortion, Miscarriage. — Puerperal Sepsis. 

GENERAL REMARKS 

The field of the general practitioner embraces: 

I. Diagnosis of diseases of the female pelvic organs. 

a. Diagnostic palpation. 

b. Examination with specula. 

c. Examination of discharges, tissues, scrapings in the laboratory. 

II. The knowledge and management of functional disorders and neu- 
roses. 

III. The knowledge and management of localized minor ailments of 
the female genitalia. 

Major operations in gynaecology, particularly such work as requires strict 
asepsis and antisepsis, is the province of the abdominal surgeon. Pro- 
longed local treatment for discharges by douches and tampons without 
inquiry into the underlying cause or condition is as reprehensible as surgical 
treatment undertaken without proper indication other than the vague and 
indefinite pain complained of by neurotic, anaemic, and constipated women. 

The principles of gynaecological diagnosis are well laid down by Dr. G. 
M. Edebohls, of New York, in a paper read before the Clinical Society of 
the New York Post Graduate Medical School: 

"Gynaecological diagnosis, in its more restricted sense, is nearly synony- 
mous with diagnostic palpation of the female pelvic organs, and the practice 
of the latter resolves itself virtually into the practice of the bimanual touch, 
or combined external and internal palpation. 
508 



GYNAECOLOGICAL DIAGNOSIS 



509 



" Vaginal palpation alone and rectal palpation alone have absolutely 
no place in modern gynaecological diagnosis, and consequently in furnishing 
indisputable indications for treatment. 

"To illustrate: Vaginal touch suffices to establish a diagnosis of cancer 
of the cervix; bimanual examination, however, is necessary to determine 
whether the case is still an ' operable ' one. The condition of the ovaries 
and tubes can be satisfactorily made out only by the bimanual; yet who 
would be willing, at the present day, to undertake the active treatment 
of any gynaecological case without first knowing the condition of the ovaries 
and tubes? 

"Abdominal palpation, though by itself of little or no value in the 
diagnosis of pelvic disorders, cannot be dispensed with in the modern prac- 
tice of gynaecology, since many conditions of the abdominal organs, notably 
movable kidney and appendi- 
citis, which so often produce 
symptoms complicating and 
counterfeiting disease of the 
pelvic organs, can only be rec- 
ognized in this way. 

" We shall first speak of 
gynaecological diagnosis as far 
as it can be made by the fin- 
gers alone, without the assist- 
ance of any instrument what- 
soever. As already stated, a 
diagnosis thus arrived at will 
suffice in the vast majority, 
certainly over 95 per cent, of 
all cases. 

" The practice of the bi- 
manual touch will vary some- 
what in its details according 
as it is undertaken in a well equipped office or hospital or at the home of 
the patient. The office examination, furnishing the standard of conditions 
under which bimanual palpation is practised to the greatest advantage, 
will be first considered. 

"The indispensables to a satisfactory practice of the bimanual touch 
are a good examining chair or table and proper leg holders. Quite an 
array of both are in the market to suit various fancies, tastes, and purses. 
As for the tables, nearly every one of them will answer the purpose, the 
choice between them narrowing itself down to a question of appearance, 
of greater or less convenience, of adaptability to uses in addition to those 
of diagnosis, as well as of personal predilection arising from familiarity 
and habit. A point of some importance is to have the table of the proper 
height to suit the examiner, so as to avoid the fatigue of stooping and 
strained positions. 

" Many of the leg holders or heel rests in common use are objectionable 
on the score of the constrained position of the patient and incomplete 
relaxation of her muscles. The Edebohls leg holders act on the principle 
of suspending the lower extremities by the ankles, with the legs and thighs 
flexed, the knees falling apart by their own weight. Thus every muscle of 
the lower extremities, pelvis, and abdomen is relaxed and the bimanual 
examination greatly facilitated. 

" Immediately preceding each examination, the patient should empty 




Fig. 158. — Stocking and Strap Leg Holder in 
Dorsal Posture. 



510 



THE GENITOURINARY SYSTEM 



the bladder. It is desirable, though not always as convenient, nor as 
imperative as in the case of the bladder, to have the rectum also empty. 
After removing her corset and loosening every article of apparel about the 
waist, the patient is ready for examination. 

"The patient is then placed in position on the table, upon the back, 
with her buttocks at the edge of the table and her feet or legs sustained by 
suitable leg holders. Whether she lies with the upper part of the body 
somewhat elevated or perfectly flat makes little or no difference when 
the Edebohls leg holders are used. With other leg holders it is preferable 
to have the head and thorax somewhat raised. Unnecessary exposure of 
the person should be avoided, and the patient's feelings of modesty should 

receive all due respect possible un- 
der the circumstances. 

"The examiner now takes his 
position at the foot of the table, and 
introduces the index finger of one 
hand into the vagina, carrying it 
along the posterior wall so as to 
avoid the sensitive parts of the ves- 
tibule, until the cervix uteri and 
vaginal vault are reached. 

" The fingers of the other hand 
are placed upon the lower abdomen 
in such a manner that all the or- 
gans of the pelvic cavity successively 
come to lie between, and are palpat- 
ed bv, the internal and the external 




Fig. 159. — Bimanual Palpation of Female 

Pelvic Organs. 
First step. Locating the fundus and cervix. 
(After Kelly). 



fingers. 



"Obstacles to successful vagino- 
abdominal palpation, the bimanual 
examination as generally practised, 
are a short vagina, unusually high 
position of the uterus and of its annexa, and a well developed panniculus 
adiposus. These obstacles can in nearly every case be overcome by com- 
bined rectovaginoabdominal palpation. 

" In practising rectovaginoabdominal palpation the fingers of one hand 
are placed on the lower abdomen in the usual way. The index finger of 
the other hand is passed into the vagina, while the middle finger of the same 
hand enters the rectum. Or the thumb may be passed into the vagina and 
the index finger into the rectum, at the option of the examiner. 

" Experience here as elsewhere is an important item, and the experienced, 
well oiled finger can be so deftly and gently introduced into the bowel and 
beyond the so called third sphincter as to give the patient absolutely no pain. 
The disagreeable sensation of an impending fsecal movement is the only 
thing complained of, and this passes away instantly the finger is withdrawn. 

"By means of the rectovaginoabdominal touch the examining fingers 
penetrate the pelvis to a much greater depth, the perin£eum being carried 
upward to the extent of about three centimetres upon the web between the 
vaginal and rectal fingers. 

"To satisfactorily and completely fulfil its mission as an explorer, the 
rectal finger must penetrate beyond the third sphincter, the situation of 
which corresponds in height with that of the os internum. Under ordinary 
circumstances the posterior surface of the uterus, as well as the tubes and 
ovaries, is thus palpated with the greatest facility. 



BIMANUAL PALPATION OF FEMALE PELVIC ORGANS 



511 



" Elevation of the pelvis, the Trendelenburg posture, by causing the 
abdominal viscera to gravitate away from the pelvis, will occasionally prove 
a useful adjuvant in the performance of the bimanual. 

" The bimanual examination of virgines intactce should always assume the 
form of a rectoabdominal palpation. There is no need in these cases of a vag- 
inal examination; the finger in the rectum will teach us all we wish to know 
concerning uterus, tubes, and ovaries. The only difficulty to be overcome 
is to identify the cervix; a little practice will enable us to master this detail. 

"An excessive deposit of fat over the lower abdomen and the buttocks 
forms one of the most common of the ordinary difficulties to be overcome 
in bimanual palpation. In this connection it is well to remember that very 
fat women present a transverse crease or furrow, deeply indenting the pan- 
niculus adiposus, just above the pubes. By passing the finger tips of the 
outer hand down to the bottom of this furrow or crease, the examination 
will sometimes be possible where, without this little artifice, it would fail. 
In any event, however, most of the fine palpatory work in fat women will 
have to be performed by the vaginal and rectal fingers. 

"Gentle, light, and deft palpation will aid us in gaining the confidence 
and cooperation of our patient, and will often succeed where brusqueness 
and uncalled for exertion of strength will fail. By pressing so. hard as 
to cause the patient pain we provoke 
the abdominal muscles to contrac- 
tion in self-defense, and thus directly 
defeat our purpose, besides exhaust- 
ing the muscles of forearms and fin- 
gers and blunting our sense of touch. 

"The sense of touch, the tactus 
eruditus, is the gynaecologist's stock 
in trade. Without it he could no 
more pretend to practise gynaecology 
than a blind man could practise 
ophthalmology. A finely developed 
tactus eruditus is not to be looked 
upon as an innate gift; it is solely 
the result of daily, patient, and 
painstaking cultivation. 

" A first examination of a patient 
at her house should never be made 
with her in bed unless her removal 
would be attended with risk. A firm 
table, strong enough to bear the pa- 
tient's weight, is our first choice. In lieu of that, the head end of an 
ordinary sofa may be used to support the patient's buttocks, her back and 
head resting upon pillows appropriately disposed upon the body of the sofa. 
With the patient's knees separated and drawn up toward her face and held 
there by her own or by a friend's hands, an excellent posture for the prac- 
tise of the bimanual touch is obtained. 

" Occasionally, though less and less frequently with increasing experience, 
examination under narcosis becomes necessary in order to establish a satis- 
factory diagnosis by bimanual palpation. It is scarcely necessary to add 
that when the patient submits to the unpleasantness and risk attending the 
administration of an anaesthetic, she has a right to expect that the verdict 
reached shall be final, and that, therefore, only a thoroughly competent 
examiner should officiate on the occasion. 




Fig. 160.— Bimanual Palpation of Female 

Pelvic Organs. 
Catching the appendage between the tips of 
the opposing fingers. 



512 



THE GENITOURINARY SYSTEM 



"The examiner will occasionally avail himself of the relaxing effects of 
the hot bath to overcome excessive rigidity and hyperaesthesia of the ab- 
dominal walls, the examination being made immediately after the emer- 
gence of the patient from the bath. 

" Before we proceed to the consideration of the pathological conditions 
of the female pelvic organs recognizable by bimanual palpation, it may 
be well to describe briefly the normal findings. 

" Under favorable conditions, with proper posturing of the patient, 
bimanual examination should furnish us a clear picture or conception of 
the size, position, consistence, etc., of the following structures and organs: 
Anus, vulva, vagina, urethra, bladder, the lower five to six centimetres of 
the ureters, the rectum to beyond the third sphincter, cervix, uterus, tubes, 
ovaries, pelvic cellular tissue and peritonaeum, walls of the pelvis, and the 
broad, round, and uterosacral ligaments. 

" Palpation of the ovarian ligaments is often a difficult matter, although 
of the greatest importance and almost pathognomonic significance in the 
diagnosis of small ovarian tumors. 

"In making gynaecological examinations it is well to accustom one's 
self from the very beginning to a certain system or order, as regards both 
the examination itself and the record thereof. The general custom is to 
begin with the perineum and to examine and record in ascending order 
the condition of the organs and structures enumerated above. The real 
examination, however, begins with the tubes and ovaries in all cases in 
which these structures can be reached and defined. The condition of the 
tubes and ovaries is of such essential and prime importance in diagnosis, 
prognosis, and the formulation of therapeutic indications that we cannot 
afford to forego exact knowledge thereof in any case. 

"The findings on examination are then noted and recorded, beginning 
with the ovaries and tubes. The fundus of the uterus, our guide to the 
tubes, and along these to the ovaries, is the first thing sought for by the 
palpating internal and external fingers. The promontory of the sacrum 
is the next point to be located. It forms the principal landmark in the 
determination of dislocations of the uterus, tubes, and ovaries, as well as of 
their degree. 

" Having introduced the finger or fingers to the proper depth in vagina, 
or vagina and rectum, the abdominal wall is depressed by the fingers of the 
external hand until the finger tips of one hand recognize, or practically 
meet, those of the other behind the uterus. This presupposes, of course, 
a uterus not enlarged by pregnancy or the presence of a tumor and not im- 
pacted in retroversion in the pelvis. We are now ready to proceed to the 
palpation of tubes and ovaries, and with this palpation, as already stated, 
begins the examination proper. 

" Palpation of the ovaries is best accomplished by following the tube 
from the uterine cornu outward to the ovary. This will sometimes pro ye 
impossible of accomplishment from the vagina, on account of inelasticity, 
thickening, or senile atrophy of the vaginal walls. Examination per 
rectum will enable us to overcome all difficulties of this sort, and to recognize 
with the greatest distinctness normal sized tubes and ovaries, especially 
when prolapsed backward with a retroverted fundus uteri. Indeed, by 
artificially dislocating the fundus backward by pressure with the fingers 
of the outer hand we can, in practically all cases, bring the ovaries and 
tubes within easy reach of the rectal finger. 

" Having satisfied ourselves that the ovaries are normal in size, we next 
test them for sensitiveness on pressure. In doing so we must avoid being 




DIAGNOSTIC PALPATION OF FEMALE PELVIC ORGANS 



513 



deceived by the presence of a lumboabdominal neuralgia as denoted by a 
Valleix point in the anterior abdominal wall near the median line. In 
distinguishing we shall remember that in mural neuralgia the pain on 
pressure is very localized and is elicited by pressure of an external finger 
alone; while the pain of oophoralgia or oophoritis is elicited by pressure of 
the internal finger or, better still, by compression of the ovary between the 
inner and outer fingers. Tenderness of the appendix vermiformis may, in 
rare instances, prove difficult to discriminate from ovarian pain on pressure. 
Palpation of the appendix from without will eliminate this possible source 
of error. 

"A calculus lodged in the lower end of either ureter may be mistaken 
for a cirrhotic ovary. The diagnosis is cleared up by determining the 
presence or absence of a normal ovary on the same side with the doubtful 
hard body. 

" In all tumors of suspected ovarian origin the diagnosis can be made 
absolute only by determining the relations of the ovarian ligament to the 
tumor. When this ligament can be distinctly traced running from the uterus 
on to the tumor, we know the tumor must be ovarian. This is, however, by 
no means always an easy task, even when we resort to artificial dislocation of 
the uterus either upward into the abdomen or downward toward the pelvic 
outlet. The recognition of a normal ovary beneath or alongside of a pelvic 
tumor of doubtful origin will of course enable us to exclude ovarian tumor. 

" Palpation of the normal sized Fallopian tubes is to-day the common 
property of all thoroughly trained physicians, and offers no difficulties 
under ordinarily favorable conditions. The tubes are felt between the 
internal and external fingers as rounded cords extending from either cornu 
uteri outward to the pelvic wall. The direction of the outer half of the 
tubes serves to distinguish these organs from the round ligaments; the 
relative position of the two structures also aids in their distinction. 

"Perfectly normal tubes are non-sensitive on pressure, even as the 
healthy uterus itself. When the fingers recognize a normal sized tube, 
sensitive on pressure, while an equal degree of pressure immediately above 
and below the tube fails to elicit pain, the diagnosis of salpingitis, probably 
catarrhal, must be made. Reasoning backward from the salpingitis, a 
causative endometritis is the logical deduction, even though all the other 
usual symptoms of the latter are absent. In the absence of contraindica- 
tions, curettage and drainage of the uterus are the measures called for. 

"In cases of movable retrodeviated uteri, exact palpation of the tubes 
and ovaries is sometimes more easily accomplished after lifting the fundus 
forward bimanually. 

"In the severer forms of salpingitis the ovaries, pelvic peritonaeum, and 
adjacent organs are generally more or less involved. An attempt to de- 
scribe the almost endless variations in the physical signs produced by 
these complications would lead us too far. 

"Whenever the tubes, in these complicated conditions, form the focus 
or starting point of the inflammatory process, and yet are not of themselves 
very greatly enlarged, it becomes a matter of practical importance to de- 
termine, if possible, whether the tubes maintain their normal direction, 
running straight outward from the horns of the uterus, or whether they 
are prolapsed backward into Douglas's sac, spiral in their course, club- 
shaped, or very irregularly thickened. Under the first named circumstances 
curettage and drainage of the uterus, followed by an energetic ichthyol 
therapy, might still lead the case to a favorable termination, while with the 
last named conditions present more radical measures would be indicated. 



514 



THE GENITOURINARY SYSTEM 



"A tubal tumor can, in most instances, be diagnosticated by bimanual 
palpation, more especially if we succeed in recognizing the ovary of the same 
side. The diagnosis as to the character of the tubal tumor, whether it be 
heemato-, hydro-, or pyosalpinx, tubal pregnancy, tuberculosis, actinomy- 
cosis, cancer, or other malignant tumor, cannot, however, be made with any 
approximation to certainty by bimanual touch alone. If a tubal tumor 
is suspected, the examination should be conducted as gently as possible, 
the possibility of rupture during manipulation being constantly borne in 
mind. 

" The diagnosis of occlusion of the abdominal end of the tube may occa- 
sionally be prognostically, as well as therapeutically, of practical value. 
This diagnosis becomes probable when the outer end of the tube can be 
felt as a club-shaped enlargement with adhesions to neighboring parts. 

" The various uncomplicated displacements of the uterus are readily 
recognized on bimanual palpation, especially by the rectovaginoabdominal 
touch. In this connection the various physiological displacements of the 
uterus, due to overdistention of bladder or rectum, as well as to the posture 
of the patient, must not be lost sight of. 

"Quite a different matter is the diagnosis of displacements of the uterus 
when these displacements are the result of disease processes outside of the 
uterus itself. The uterus may be dislocated in any and every direction by 
tumors of adjacent viscera, by para- and perimetritic exudates, scars, and 
adhesions. 

" It is often extremely difficult to recognize the uterus when buried in 
the conglomerate pathological masses thus produced. Our chief aids in 
the discovery of the uterus, under these circumstances, will be the recog- 
nition of the continuity between cervix and body, as well as the form, size, 
and consistence of the uterus itself. This peculiar consistence of the uterus, 
under varying conditions, can only be learned from considerable experience 
and is almost impossible to describe. A knowledge thereof is of invaluable 
aid in diagnosis. 

" The rectovaginoabdominal touch will furnish valuable information 
regarding the presence or absence of adhesion in cases of retroversion of the 
uterus. The therapeutic indications in a given case will depend upon this 
information. 

" Inversion of the uterus is completely and satisfactorily diagnosticated 
by bimanual palpation. A depression is felt where the fundus uteri should 
be, and the tubes and ovaries are recognized arising from the depths of 
the depression. 

" The diagnosis of tumor of the uterus by bimanual palpation is easy 
in those cases in which the continuity of cervix or corpus with the tumor, 
or the connection of the tumor with the uterus by a pedicle, can be traced. 
Failing in this, we must have recourse to other diagnostic aids: contour and 
consistence of the tumor mass, the history of the case, etc. 

" Many forms of developmental anomalies of the uterus are recogniz- 
able by bimanual touch. Thus, the most frequent and practically important 
form of arrest of development is manifested by the coexistence of a large 
cervix and a small corpus, with probably undersized tubes and ovaries. 

"A uterus unicornis is recognized by normal insertion of the tube and 
round ligament on one side, while on the other side these structures are 
inserted into the uterus at the level of the os internum. 

" The diagnosis between a double uterus and a tumor connected with a 
single uterus is made by tracing the tubes. If these originate from the outer 
side of either mass, we have a double uterus to deal with. 



DIAGNOSTIC PALPATION OF FEMALE PELVIC ORGANS 



515 



" In the diagnosis of diseased conditions of the cervix we are not depend- 
ent upon palpation alone ; the sense of sight may be brought to our aid. 
Nevertheless, the various pathological states affecting the cervix uteri, 
hypertrophy, elongation, lacerations, ectropium mucosae, inflammation, 
polypus, carcinoma, etc., may all be recognized and distinguished with 
absolute certainty by the trained finger alone. 

" Hegar's sign, the compressibility of the lower segment of the uterine 
body, as demonstrated by the bimanual touch, is, in the hands of the expert, 
a pathognomonic sign of pregnancy in the early months. A note of warning 
in the examination of cases of suspected pregnancy is in order, for it is 
known that the bimanual, too vigorously applied, may produce abortion, no 
instrument whatsoever having been used. 

"The female bladder can be outlined throughout its whole extent and 
the presence within it of a tumor, concretions, or foreign body can be de- 
termined by the bimanual touch. 

" With the bladder empty, the lower five to six centimetres of the ureters 
may be palpated, and dilatations and thickenings of that canal, as well 
as concretions within it, can be distinctly felt. The importance of these 
findings from a diagnostic point of view can scarcely be overestimated. 

" Regarding the diagnosis by palpation of the various pathological changes 
in the pelvic cellular tissue and the pelvic peritonaeum, parametritis, 
perimetritis, hsematoma, and hsematocele, I will merely call attention to two 
points of great practical importance upon which sufficient stress is not 
usually laid. The first is the fact that in a first attack of acute peritonitis, 
pelvic or general, in a woman, our earliest positive diagnostic sign consists 
in a sense of fulness and fluctuation in Douglas's sac, easily recognizable by 
vaginal or, better, by combined rectal and vaginal touch. The second 
relates to cases of carcinoma of the uterus ; if the sacral glands can be felt 
to be even slightly enlarged and tender, the case, no matter how favorable 
the other conditions may be, is probably beyond the help of operation. 

" An examination with a bivalve, cylindrical, or jSims speculum is made 
in the dorsal or left lateral position. It reveals the appearance of the parts 
which can be brought to view and the character of the discharge if present. 
The uterine sound may be used for determining the depth of the uterus and 
the course and patency of the cervical canal. Its employment for diagnostic 
purposes is indicated only in very exceptional cases, and great care must be 
taken to avoid sounding a gravid uterus by mistake, and to avoid injury 
and infection of the uterus by the use of an unclean sound or forcing inward 
of septic material from the vagina and cervical canal. In sounding the 
uterus asepsis must be as perfect as for major operations. 

" Exploratory puncture of the female pelvic organs through the vaginal 
walls or abdominal parietes for the purpose of establishing the presence or 
absence and the character of pus, blood, cystic fluid, etc., in deepseated, 
fluctuating swellings is rarely called for. This method is not for universal 
use, and is safe only in the hands of an experienced diagnostician. If the 
physician has reason to suspect the presence of recent venereal infection, 
in the case of the patient to be examined, a rubber glove should be worn— -a 
finger cot will protect the finger only. Scrapings and discharges should be 
collected in wide mouthed bottles for laboratory diagnosis. Too much 
reliance should not be placed on microscopical diagnosis. 

" Palpation of the female pelvic organs, although it may have revealed to 
us minutely and satisfactorily the condition of these organs, is insufficient 
in itself for a diagnosis complete enough to satisfy the demands of modern 
gynaecology. The entire abdomen calls for careful palpation, especially with 



516 



THE GENITOURINARY SYSTEM 



reference to the so frequent and important conditions of movable kidney 
and appendicitis. The other important organs of the body, heart, lungs, 
kidneys, and brain, must also be interrogated for evidences of disease. Even 
when we have thus gone over the whole field, and recorded the results 
of our physical examination, the diagnosis is not complete. The establish- 
ment of a scientific diagnosis calls for an analysis of the subjective symptoms 
of the patient, with the view of harmonizing them with the objective signs. 
In other words, each prominent symptom complained of must be traced to 
its source, and analytically referred to its causative condition, the latter 
having been determined by physical examination. Only after this is done 
and the indications for treatment clear, are we able to act intelligently in 
the attempt to help our patient. This forms a high standard of practice, 
but progressive modern medicine and modern gynsecology are satisfied with 
nothing less at the present day." 

MENSTRUAL DISORDERS 

Menstrual Condition of the Average Girl in Average Health. — The late 
Dr. George J. Engelmann, of Boston, has presented an interesting statistical 
paper on this subject, and the facts presented by him were culled from the 
records of forty-eight hundred and seventy-three cases from high and 
normal schools, colleges, and department stores. The girls were between 
fifteen and twenty-six years old, the majority between eighteen and twenty- 
two, in rather better than average health — in good health — and in numbers 
sufficient to admit of positive deductions as to what may be termed normal 
or average menstruation. 

The average period of the average girl in average health presented very 
different features: Regularity in 50 per cent of the cases only; recurrence 
every twenty-eight days in 30 per cent, varying most frequently from 
twenty-six to forty-two days, 45 per cent being over twenty-eight. The 
duration varied from two to seven days, average 4.6. From 66 to 70 per 
cent suffered more or less, the number of sufferers varying, according to age 
and nature of occupation, between 30 and 90 per cent. Lessened ability 
for exertion, mental or physical, was admitted by 60 per cent. Some few 
were habitually incapacitated from work, and 30 per cent occasionally. 
The function of the girl in good health, under modern conditions of life, 
was by no means an ideal one in the judgment of the essayist. 

' Amenorrhoea, or absence of menstruation, between puberty and the 
menopause, and late menstruation in girls, are not of infrequent occurrence. 
In the unmarried they are due chiefly to anaemia or chlorosis and grave 
wasting diseases, such as phthisis. In the married or unmarried they may 
be caused by non-development or atrophy of the generative organs, nerv- 
ous affections, change of climate, increasing obesity, and removal of the 
ovaries and tubes. Absence of menstruation is normal during pregnancy 
and lactation. 

Emansio mensium (a term applied to those cases in which menstruation 
has never appeared) is generally free from any symptoms; suppressio 
mensium is usually accompanied by the symptoms of the disease which 
causes it. The patients often complain of a feeling of fulness in the pelvis; 
of headache, flushes, and general nervousness. 



MENSTRUAL COLIC; DYSMENORRHEA; INTERMENSTRUAL PAIN 517 

The treatment of functional amenorrhoea in absence of imperforate 
hymen consists of hydrotherapy and judicious exercise. The cool douche is 
efficient, also massage and vibratory massage. The diet should be liberal 
and digestion may be aided by giving five drops of dilute hydrochloric acid, 
in water, after meals. The bowels should move once a day. In anaemic 
conditions, iron, bromomangan, iron tropon, and arsenic are indicated. 
A sea voyage is beneficial, and in some instances the administration of 5 
grains of powdered thyreoid gland twice daily has been followed by the 
desired results. In general obesity the management for obesity must be 
rigidly carried out. When the usual, rational means of treatment fail to 
establish the evidence of the functional activity of the pelvic viscera, a 
careful examination is indicated, preferably from the rectum, in the case of 
intact virgins. Should a retention of menstrual fluid be due to an imper- 
forate hymen, the latter must be incised. 

Menstrual Colic; Dysmenorrhea; Intermenstrual Pain; Lumbar Neuralgia 

Dysmenorrhoea is not a disease per se; it is simply pelvic pain or colic 
associated with pelvic congestion and is a symptom common to numerous 
diseases. 

Dysmenorrhoea therefore may be local or pelvic, general or constitu- 
tional, or reflex in origin. Thus, we find dysmenorrhoea in neurotic and 
hysterical women, in anaemic, undernourished, and constipated women, 
in chronic malarial poisoning, in stenosis of the os or uterine canal, in im- 
perfect development of the uterus (small body and large cervix), in flexions 
and malpositions of the uterus, in uterine and pelvic tumors (fibroids), 
and in circulatory disturbances (heart disease). 

The purely neuralgic form of dysmenorrhoea may be of the nature of 
an autointoxication from intestinal putrefaction, for it is well known that 
certain toxic substances have a predilection for irritating certain nerve 
tracts, a fact which is frequently overlooked in the therapeutic management 
of all forms of neuralgia. 

Dysmenorrhoea, therefore, is produced in various ways by various 
pathological conditions and by a combination of some or all of these con- 
ditions, and the therapeutic management of a case of dysmenorrhoea must 
be the outcome of a careful study and analysis of the underlying patho- 
logical condition. 

Treatment. — The palliative treatment comprises hot applications, pro- 
longed hot sitz baths, rest in bed, hot drinks, hot bags to the lumbar spine, 
and antipyrine. Dilatation of the cervix brings temporary relief, but this 
is seldom permanent. The interim treatment of dysmenorrhoea will con- 
sist of hydrotherapy, exercise, massage, vibratory massage, and tonic 
medication. 

Intermenstrual pain and iliolumbar neuralgia require painstaking inves- 
tigation as to their origin. Hydrotherapy, attention to the bowels, and 
wearing an abdominal supporter are usually indicated. 

Menorrhagia, or prolonged or excessive menstrual flow, and metrorrhagia, 
or haemorrhage from the uterus occurring independently of menstruation, 
may be the result of general and local causes; thus, violence of emotion 



518 



THE GENITOURINARY SYSTEM 



and sexual excitement, diseases of the heart, lungs, and liver, endometri- 
tis, retained secundines, subinvolution of the uterus, tumors of the uterus, 
fibroid and cancer, and fungous granulations of the endometrium. Extra- 
uterine pregnancy is usually associated with irregularities of menstruation. 
At puberty menstruation is frequently scanty, delayed, or omitted. 

Irregularities during the middle period of married life are quite common 
among those who have been repeatedly pregnant and have had household 
cares in abundance. It is of great importance that such cases should be 
carefully followed and the presence of disease of more or less serious character 
discovered in time to treat it effectually. Myoma uteri at such a period 
is most likely to be troublesome, and the effort should be made to distinguish 
it from malignant disease at the earliest moment. Irregularities due to 
the presence of fissured or lacerated cervix are often relieved by amputation 
of the cervix. Women with the haemorrhagic diathesis may show purpuric 
spots at the time of profuse bleeding. 

The treatment should be directed against the individual causes. Haem- 
orrhages resulting from endometritis, retained secundines, and fungosities 
usually yield promptly to curetting of the uterine canal. In the absence of 
local disease, rest in bed and the general "hygienic management outlined 
under amenorrhcea are indicated. A lax abdomen should be reenforced 
by wearing an abdominal support. Absence from home and home cares is 
often curative in this class of cases. Fluid extract of ergot and gossypium, 
20 drops of each, twice a day, may be given empirically in undue haemorrhage 
from the uterus. A very excellent haemostatic is hydrochloride of hydrasti- 
nine, gr. \, three times a day. 

By vicarious menstruation is understood a periodical discharge of blood 
from some part of the body other than the interior of the uterus. The 
exact cause of this condition is not known ; diseases of the blood or its vessels 
seem to play an important part in the aetiology. The treatment is symp- 
tomatic. 

The Menopause and Premature Menopause 

The fallacy that the change of life is a critical and dangerous time is 
still a widespread opinion and ranks with teething as an all round aetio- 
logical factor for various derangements. Nervous and vasomotor disturb- 
ances are common enough in the menopause period, but they respond ad- 
mirably to the suggestion therapy and general hygienic measures. In 
cases of dire necessity bromides may be offered with a view of subduing the 
excitability of the quasi patient. 

Haemorrhage during the menopause, if frequent, is usually an evidence of 
a diseased endometrium and occasionally a sign of malignant disease. The 
differential diagnosis between simple, carcinomatous, syphilitic, and tuber- 
culous endometritis is by no means easy, because a microscopical diagnosis 
in the hands of the inexperienced is not to be relied upon. Curettage for 
diagnostic purposes is a legitimate and proper procedure in all doubtful 
cases. As soon as the causation of haemorrhage has been definitely estab- 
lished, the treatment is self-evident. Empirical medication for uterine 
haemorrhage is mentioned under Menorrhagia and Metrorrhagia. 

Cases of complete and rather sudden and early cessation of menstruation 



STERILITY IN THE FEMALE 



519 



are occasionally observed in the absence of local disease of the generative 
organs. In such instances we may assume that the lesion is located higher 
up in the nerve centre controlling the menstrual function. 

The treatment of this condition will be in accordance with the under- 
lying condition, if it can be detected. The usual hygienic management is 
indicated. Vibratory massage over the pelvic organs may be tried, also 
the internal administration of powdered thyreoid gland, 5 gr. twice daily. 
In anaemic women iron, arsenic, phosphorus, and a generous diet are to be 
recommended. 

INCONTINENCE OF URINE IN THE ADULT FEMALE 

This condition is met with occasionally in two forms: with the first 
the patient has no desire to urinate, but finds that her clothing is wet after 
sneezing or coughing ; with the second form there is a desire to urinate and 
there is an attempt to control it, but the flow of urine takes place suddenly. 

The causes which lead to incontinence are many. We are apt to find it 
associated with nervous disorders, trivial and grave, with prolapse of the 
bladder, rectum, or uterus, with general enteroptosis, after forcible dilata- 
tion of the urethra, with calculi and polyps within the urethra, or with 
tuberculosis of the bladder and congenital malformations. 

The treatment of this condition must be directed to the underlying 
cause. The cold douche, wearing an abdominal binder, electricity, and 
massage should be tried. In suitable cases operative procedures are called 
for. 

STERILITY IN THE FEMALE 

In primary sterility, in which pregnancy has never occurred, the hus- 
band is to blame in about one case out of four (faulty semen) . The term 
secondary sterility applies to women who have been pregnant once and 
fail to become pregnant again. 

Causes. — Dr. Brothers, of New York, states that in 180 women who were 
considered responsible for the trouble the causes of the sterility were classi- 
fied as follows: 



General Conditions: 

Obesity, . . 7 cases. 

Alcohol and morphine habit, 1 

8 

Pelvic Peritonaeum: 

Pelvic abscess, 1 

Pelvic tumor (?), 3 

Pelveoperitonitis, ■. 14 

— 18 

Annexa : 

Undeveloped ovaries, 6 

Ovarian tumor, 9 

Salpingo-oophoritis, 28 

Pyosalpinx, 7 

50 

34 



520 



THE GENITOURINARY SYSTEM 



Cervix and Uterus: 



Pinhole os, 5 

Conical cervix, 1 

Stenosis of cervical canal, 22 

Undeveloped uterus, 14 

Retrodisplaced uterus, 22 

Anteflexed or anteverted uterus, .... 7 

Prolapsus uteri, 2 

Fibroids, 5 

Endometritis and endocervicitis, 15 



CASES. 



93 



Vulva and Vagina : 

Unruptured hymen, . 

Vaginal bands, 

Vaginismus, 

Gonorrhceal vaginitis, 



1 
1 

3 
6 



11 



Total, 



180 



The management of sterility of the female will depend entirely upon the 
underlying cause and should not be undertaken without prior examination 
of the male. In those cases in which a lesion can be definitely located and is 
accessible, the prospect of a desired pregnancy is offered by means of minor 
or major operative measures, under antiseptic precautions. 

When sterility is due to general debility in the female and errors in the 
male, surgery upon the female will not assist nature. The legitimate cases 
for treatment of the sterile condition are those of women with stenosis of the 
mouth of the womb, but with sound ovaries and tubes and the pelvis free 
of gonoccoci. 

The Effect of Castration on Women. — The natural menopause closes the 
natural mission of the woman, and in the majority of women who have been 
castrated the sexual impulse abates in intensity much sooner than after a 
natural menopause, and in some cases wholly disappears. 



This is a painful spasm of the muscles surrounding the lower part of 
the vagina and the vulva, occasionally observed in newly married neurotic 
women with a rigid hymen, urethral caruncle, ulcer, fissure, or some in- 
flammatory condition around the vulva. 

Treatment. — Remove the underlying cause and suggest to the sufferer 
the feasibility of overcoming the difficulty by will power. Dilate the vagina 
if necessary under narcosis. A vaginal suppository of opium, belladonna, 
and cocaine, introduced half an hour before sexual intercourse, is efficacious, 
as are also local applications of 4 per cent cocaine solution to the vulva. 

Masturbation. — The production of a venereal orgasm by the hand and 
other artificial means is called masturbation. Local cleanliness, the removal 
of local irritation (constipation, worms), moral and hygienic management, 



VAGINISMUS 



VULVOVAGINAL DISCHARGES 



521 



the avoidance of bad companions and literature, and the exercise of will 
power are the means of overcoming this evil. 

Nymphomania is a morbid irresistible impulse to satisfy the sexual appe- 
tite peculiar to the female sex. When it is of a purely neurotic type without 
local disturbances, it requires tactful and stern measures such as will sug- 
gest themselves to the guardian or physician of the afflicted. 

VULVOVAGINAL DISCHARGES 

A vaginal discharge is not always a sign of disease of the pelvic organs. 
It is frequently met in patients suffering from heart, blood, or lung disease, 
in pregnancy, as a result of uncleanliness or trivial local irritation, and 
in anaemic and constipated girls and most married women. Patients 
troubled with a vaginal discharge usually complain of backache, a feeling 
of heat in the vagina, vesical or rectal irritability, more or less severe itching, 
general debility, etc. On inspection the vagina is found to be red, perhaps 
granular or cystic in places. The discharge is either mucopurulent (leucor- 
rhcea), purulent (gonorrhoea (?)), or hemorrhagic (neoplasm (?)). A careful 
examination of the discharges which do not yield to mild measures should 
always be made, as it may reveal the presence of gonorrhceal infection or 
incipient malignant disease. 

Treatment. — Simple leucorrhcea yields to cleanliness, attention to the 
bowels, and general hygienic management. Occasionally medicinal tonics, 
such as iron tropon and bromomangan, are indicated in ansemic and debili- 
tated women. In purulent, non-specific leucorrhcea more local treatment in 
the way of douching is indicated in addition to the above mentioned meas- 
ures. A douche of sulphocarbolate of zinc (3j to the pint) or of sulphate of 
zinc and acetate of lead combined (5j) should be employed twice or three 
times a day, to be followed by a sitz bath. Ichthyol may be used as a douche 
in 5 per cent solution and in the form of 5 grain rectal suppositories. Swab- 
bing the vagina with 2 per cent nitrate of silver solution at intervals of 
two or three days may assist in reestablishing a healthy action of the 
vaginal mucosa. Sexual intercourse should be interdicted pro tempore, 
on account of the undesired irritation of the parts and the danger of setting 
up a non-specific urethritis in the male. In leucorrhcea. and backache a 
supporting belt should be worn. 

Gonorrhceal discharges in the female require all the aforementioned 
precautions and treatment until a cure is effected. An abatement of acute 
symptoms is not a sign of a cure. Recrudescence of symptoms is more the 
rule than the exception, as gonorrhceal infection may be dormant and latent 
in the female, as in the male (see also Venereal Disease). 

Endometritis and Vaginal Discharges. — Inflammation of the uterine 
mucosa may have its seat in the body of the uterus or in the cervical lining. 
Infection of the uterine cavity may come about in the same way as in the 
case of other cavities with an open outlet. Sexual contact, unclean fingers 
and instruments, and the manipulations incident to parturition and abortion 
are among the causes to be emphasized. 

The symptoms of an acute attack are dull, aching pain, irritability of the 
bladder, a purulent discharge, tenderness on palpation, and a fever tem- 
perature. 



522 



THE GENITOURINARY SYSTEM 




Fig. 161. — Supporting Belt. 



The treatment of acute endometritis is rest in bed, vaginal douches of 
warm water, free catharsis, liquid diet, and a hot water bag to the abdomen. 
Opium and belladonna, gr. ^ each of the extract, in the form of suppositories, 
may be applied once or twice a day, to relieve pain. Curettage is not indi- 
cated in acute endometritis. Rectal 
suppositories of ichthyol, 5 grains to 
each suppository, may be employed. 

Chronic endometritis may follow 
an acute attack or may develop in- 
sidiously from malposition, lacera- 
tion, and fibroid degeneration of the 
uterus or from gonorrhoea] and 
syphilitic infection. 

The symptoms are dull pain in 
the back and thighs and a purulent 
and often blood streaked discharge. Digestive and nervous disturbances 
set in, and the patients are undernourished, lose weight, and suffer from 
secondary anaemia and frequent headaches. 

Physical examination reveals an enlarged and tender uterus, a patu- 
lous cervical canal, and erosions and granulations at the os. The charac- 
teristic discharge may be seen escaping from 
the uterus. 

The treatment of this condition will de- 
pend upon the underlying cause. The first 
requisites are the wearing of an abdominal 
binder and attention to the bowels. Marked 
malposition may require correction by opera- 
tive means, not by pessaries. 

Moderate outdoor exercise and removal 
from care and worry are important factors. 
The appetite should be stimulated by taking 
hydrochloric acid and bitter tonics combined 
after eating. Bromomangan, iron tropon, 
and other so called tonics are indicated. In 
chronic cases curettage under anaesthesia and 
antiseptic precautions should be performed 
for the removal of granulations, which are 
always present. When syphilis is suspected 
as an underlying cause, iodide of potassium 
should be given on trial. 



INFLAMMATION AND ABSCESS OF THE 
VULVOVAGINAL GLANDS 




SUB-URETHBAL 
ABSCESS 



Fig. 162.— (H. A. Kelly, Med. News, 
1897). 



Inflammation of Skene's Glands. — 

Skene's glands run parallel to the urethra. 
The external orifice is found in the labium urethrse. Inflammation 
of these glands from gonorrhceal or other infection results in swelling and 
tenderness to the touch. In walking or sitting the patient experiences 



PROLAPSE AND MALPOSITIONS OF THE UTERUS AND OVARIES 523 



much discomfort, but as a rule there is no pain on urination, as in simple or 
specific urethritis. 

Treatment. — Pressure and massage of the inflamed gland in order to 
empty it of its contents are often efficacious. In the event of abscess for- 
mation an incision may be made through the anterior vaginal wall into the 
abscess. 

Inflammation and Cyst of Bartholin's Glands. — Bartholin's glands are 
situated one on either side of the introitus vaginae. Inflammation of these 
glands from gonorrhceal or other infection causes considerable local dis- 
comfort, pain, swelling, and a sensation of heat and throbbing. An abscess 
frequently forms. An early incision gives prompt relief. The incision is 
best made in the lower part of the swelling. The cavity may be scraped 




Fig. 163. — Prolapse op the Ovary (C. C. Barrows, Med. Record, 1904). 



and irrigated and packed with gauze to favor healing by granulation 
and prevent recurrence. In chronic abscess the entire gland may be dis- 
sected out. 

Retention cysts of Bartholin's gland require evacuation, packing, or 
extirpation. 

PROLAPSE AND MALPOSITIONS OF THE UTERUS AND OVARIES 

Prolapse of the Uterus, Ovaries, and Bladder 

The uterus and ovaries have no absolutely fixed position, and slight 
deviations from the imaginary normal position must not be regarded as an 
object for treatment. 

Retroversion and retroflexion are usually associated, the chief causes 
of backward displacement being childbirth, traumatism, pelvic adhe- 
sions, and that general laxity of the abdominal organs which we term en- 
teroptosis. 

The symptoms are practically those that have been mentioned under 
simple leucorrhcea, and bimanual palpation will reveal the condition. 

Treatment. — If a well fitting abdominal binder fails to overcome the 
symptoms for which the patient seeks relief, operative interference may be 
indicated — ventrofixation or shortening of the round ligaments (Alexander's 



524 



THE GENITOURINARY SYSTEM 



operation). The wearing of a pessary or tampon for the correction of a 
malposition is unsatisfactory and obsolete in view of the safety of operative 
measures. 

Prolapse of the Uterus. — Prolapse may vary from a slight sinking of the 
organ to complete protrusion. Childbirth, laceration of the perineum, and 

the various causes mentioned under 
flexions are the causes of prolapse. 

The symptoms are the same as in 
other malpositions, combined with 
more marked vesical irritation. Com- 
plete prolapse may be mistaken for 
inversion of the uterus or for a 
polypus. 

The treatment is operative if an 
abdominal binder fails to give relief. 

Prolapse of the Ovary; Hernia of 
the Ovary. — Ovarian prolapse occurs 
from the same known and unknown 
causes which influence the position of 
all the other pelvic viscera. We speak 
of prolapse when the ovary rests deep 
in Douglas's pouch, such cases being 
associated generally with retrodisplace- 

Fig. 164.— Abdominal Support of Plas- ment of the uterus. 

tek and Webbing (Schmitz). The symptoms are the usual ones, 

such as backache, a dragging sensation 
in the groins, thighs, and pelvis, neuralgic pains, nauseating pains, and 
pain on coition. 

The diagnosis is readily made by bimanual palpation. 

•Treatment. — When the wearing of an abdominal binder and general 
hygienic management are not followed by a cessation of annoying symptoms, 
shortening of the round ligaments or other operative measures may be 
adopted for the purpose of anchoring the ovary in a better position. Hernia 
of the ovary into the inguinal canal or labium majus may necessitate the 
wearing of a truss or operative closure of an existing aperture. 

Prolapse of the Bladder. — In cases of lax vagina following pregnancy 
the bladder may prolapse with the anterior vaginal wall, in the form of a 
well defined boggy sac. When annoying symptoms result from such dis- 
placement, plastic operative measures, such as colporrhaphy, are indicated. 

LACERATION OF THE PERINEUM AND CERVIX 

Lacerations of the perinaeum from childbirth may be slight or involve 
the anal sphincter. Subcutaneous lacerations of muscle and fasciae are 
also observed. These injuries should be repaired by primary perineor- 
rhaphy. When this is not feasible or has been neglected, the operation may 
be performed at any subsequent time. Lacerations of the cervix uteri are 
of frequent occurrence during the first confinement. They may be unilateral 
or bilateral. The symptoms are leucorrhcea, haemorrhage, and pain. 




PELVIC HEMATOCELE 



525 



The diagnosis is made by palpation and inspection. The most effective 
treatment is amputation of the cervix. 

Fistula, Vaginovesical and Rectovaginal.— Fistulae are usually the result 
of labor. In vesicovaginal fistula incontinence of urine may be constant or 
not, according to the position of the lesion. Local irritation and inflamma- 
tion may result from the action of the urine. 

In rectovaginal fistula flatus and faeces are passed into the vagina. 

The treatment of such conditions is by plastic operations. 

ECTOPIC GESTATION 

Ectopic gestation may be recognized by the following classical symptoms: 

Symptoms. — The usual symptoms of pregnancy, Hegar's sign, non- 
appearance of menstruation, severe pain in the lower part of the abdomen 
on the affected side, repeated paroxysms of pain at intervals of days, loss of 
black blood or membrane following attacks of pain, supposed to be a men- 
strual flow, collapse in case of rupture and internal haemorrhage, marked 
anaemia and a faint pulse, fainting spells. Bimanual palpation reveals an 
enlarged uterus and free or clotted 
blood (hcematoma) in Douglas's cul-de- 
sac in case of rupture. 

The above mentioned signs and 
symptoms are pathognomonic of extra- 
uterine pregnancy, but an error in di- 
agnosis is possible, nevertheless, owing 
to irregular enlargement and retroflex- 
ion or sacculation of the gravid uterus 
or simultaneous gestation within the 
uterus and a tube. 

The differential diagnosis between 
early abortion and a ruptured tubal 
gestation sac is often impossible. 

Treatment. — The palliative treat- 
ment consists in rest and the adminis- 
tration of opiates. An ice bag may be 
applied over the heart and the seat FlG - 165.— Pelvic hematoma (C. f. 
of pain. In the event of progressive Adams - The Post Graduate >- 

weakness from internal haemorrhage, 

a consultation should be called with a view to opening the abdomen to look 
for and ligate a bleeding vessel. Extrauterine pregnancy may go to full 
term and may require laparotomy. A calcified tumor containing a fcetus is 
called a HthopcEolion. 

PELVIC HEMATOCELE 

Pelvic haematocele may develop without extrauterine pregnancy, from 
the rupture of a blood vessel or angeioma of the annexa. The symptoms 
are those of internal haemorrhage. In the event of a timely arrest of haemor- 
rhage a large blood clot in Douglas's pouch can be felt by bimanual palpation. 
This may give rise to pressure symptoms or may become infected and turn 




526 



THE GENITOURINARY SYSTEM 



into a suppurating mass, in which event incision and drainage from below 
or total extirpation from above would be indicated. 

PELVIC INFLAMMATION AND SUPPURATION IN THE FEMALE 

Infection of the pelvic organs and tissues may take place in the course 
of parturition and abortion. It may readily be brought about by unclean 
surgical manipulations, viz., soundings, curettage, and cauterization. Many 
cases are of gonorrhceal origin, as first pointed out by Noeggerath. Latent 
or unsuspected gonorrhoea in the male is the cause of the vast majority 
of cases of pelvic suppuration in married women. Some few cases of pelvic 
suppuration are of tuberculous origin or are due to an extension of the in- 
flammatory process from contiguous 
parts, and in a general way we may 
divide pelvic suppuration into that 
originating in the annexa and that of 
the pelvic tissue. 

Clinical Varieties. — The principal 
clinical varieties of pelvic inflammation 
and suppuration may be grouped as fol- 
lows: Endometritis and metritis with 
cellulitis or pelvic peritonitis, pyosal- 
pinx with and without cellulitis, pyo- 
salpinx with ovarian cyst, pyosalpinx 
with parametritic abscess, ovarian in- 
flammation, acute and chronic (cystic, 
fibroid, purulent) ; tuboovarian inflam- 
Fig. 166.— Pelvic Abscess (C. F. Adams, mation and abscess, stump and suture 
The Post Graduate). suppuration following an operation, 

appendicitis and pelvic suppuration, 
septic cystitis and pelvic suppuration, septic proctitis and pelvic suppura- 
tion, intestinal perforation and pelvic suppuration. 

Diagnosis. — The diagnosis of pelvic suppuration is made from the history, 
the symptoms, and the physical signs, as elicited by bimanual palpation. 
Parturition, abortion, traumatism, and gonorrhoea are the all important 
serological factors. The general and local symptoms are fever, chills, rapid 
pulse, pain, local discharge, and pain, tumefaction, or fluctuation on bimanual 
palpation. 

Fever may be absent, however, and pain as a symptom is of relative 
value only. Most patients complain of weakness and of a sense of pressure 
on the bladder and rectum. In pelvic peritonitis the onset is quite sudden, 
with pain and vomiting. Both legs are usually flexed, as the inflammation 
is generally bilateral in contradistinction to cellulitis, in which the onset is 
gradual, and the inflammation, tumefaction, and abscess are usually uni- 
lateral. Primary cellulitis is uncommon. If an indurated mass softens 
and presents a bulging, fluctuating mass, it is hardly necessary to resort to 
the aspirating needle for diagnostic purposes. When the pelvic organs 
are imbedded and fixed in a massive pelvic induration, it is impossible and 
unnecessary to make or attempt to make a refined diagnosis as to the parts 




C YSTIC TUMORS OF THE OVARIES AND BROAD LIGAMENTS 527 



involved. The importance of determining the leucocytosis has been over- 
estimated in gynaecological as in other disease. 

Prognosis. — Pelvic inflammation with exudation may subside without 
abscess formation, and in some rare cases small pus sacs may undergo 
spontaneous absorption in the pelvis as elsewhere, or a pus tube may dis- 
charge its contents into the uterine canal or the bladder. Pus may rupture 
into adjacent organs and give rise to a new attack of inflammation, or it may 
rupture into the abdominal cavity and give rise to general peritonitis. 

Prophylaxis. — 1. To prevent suppuration, examinations in patients 
suffering from any variety of pelvic inflammation should be made gently 
and infrequently. 2. The use of sounds and cervical dilators, under or- 
dinary circumstances, should be restricted to the operating room, where the 
parts can be thoroughly prepared and the operator, nurse, and instruments 
thoroughly asepticized. 

Treatment is palliative and operative. Rest in bed until the symptoms 
have disappeared is of prime importance. Hot vaginal douches are to be 
employed several times a day. A low enema may be given to cleanse the 
lower bowel, and rectal irrigations with hot water by means of a double 
current catheter are of great benefit to the sufferer. Rectal suppositories 
of ichthyol (gr. v) or opium and belladonna (aa, gr. ^) may be used twice 
a day. An ice bag or hot water bag may be placed over the lower part of 
the abdomen. Should a fluctuating abscess present, it may be incised 
and drained from the vagina or rectum. Massage in gynaecology is not 
looked upon with as much favor as formerly. The contraindications are 
acute inflammations, the presence of pus, and pregnancy. 

BENIGN AND MALIGNANT NEW GROWTHS OF THE FEMALE PELVIS 

Polypi 

Uterine polypi may be mucous or fibroid in character. They present no 
characteristic symptoms and are found protruding from the cervix at a 
vaginal examination made for the purpose of establishing the cause of an 
existing leucorrhcea with haemorrhage. 

Treatment. — Pedunculated growths should be twisted or cut away; 
sessile polypi may be excised. 

Cystic Tumors of the Ovaries and Broad Ligaments 

The pathological classification of ovarian cysts is made after their re- 
moval from the body. Some are unilocular and others multilocular; some 
are intraperitoneal and others are extraperitoneal. 

Symptoms and Diagnosis. — There are no pathognomonic signs pointing 
to their presence until they have reached a certain size sufficient to give 
rise to subjective and objective symptoms, such as enlargement of the ab- 
domen, a sensation of weight and bearing down, some leucorrhcea, and cir- 
culatory, respiratory, and menstrual disturbances. Tumors are readily 
recognized by bimanual palpation. Pain may or may not be present. 
When the cyst is of sufficient size to interfere mechanically with the function 



528 



THE GENITOURINARY SYSTEM 



of neighboring and displaced organs, the general health fails, the patient 
loses weight and strength, and the face assumes a characteristic pinched 
expression. Bimanual palpation reveals a normal sized uterus, frequently 
displaced, and a fluctuating swelling. In distinguishing between an ovarian 
cyst and free or sacculated ascites, mistakes may be made. Ascites and an 
ovarian cyst may coexist, in which case a puncture at different points would 
reveal two fluids of different character; when they coexist it points to 
malignancy of the growth. The diagnosis of large cysts offers more difficul- 
ties than that of small ones. A large ovarian cyst will displace the intes- 
tines; in cases of ascites the intestines float on top of the horizontal fluid. 

Dermoid Cysts of the Ovary and Ligaments 

These present nearly the same symptomatic and diagnostic features as 
the ordinary variety. When a dermoid cyst ruptures into the urinary 
bladder, the escaping solid contents, such as hairs and endothelial masses, 
may form the nuclei of urinary calculi. When small calculi are passed, to 
which hairs are attached, a dermoid cyst should at once be suspected. 

Treatment. — Pelvic cysts require removal by abdominal section. The 
mortality from this operation is quite low in the hands of aseptic and ex- 
perienced operators. 

Ovarian Fibromata 

Fibromata are the more common benign solid tumors of the ovary. 
Other forms are comparatively rare. They present the same diagnostic 
features as cysts, but they do not fluctuate and their operative removal is 
indicated when the symptoms warrant it. 

Uterine Fibroid Tumors 

Uterine myomata may be submucous, interstitial, or subperitoneal. 
Subperitoneal tumors are frequently adherent to the omentum and intes- 
tines. Myomata may undergo hyaline and malignant degeneration. Fibroids 
and cancer may coexist, but this combination is quite rare. They may 
undergo cystic degeneration. Fibroids may undermine health and shorten 
life by hemorrhage or by mechanical interference with the function of 
neighboring organs, and they may become gangrenous, but they rarely 
undergo transformation into malignant growths. Fibroids, generally speak- 
ing, are benign but not harmless, and are a common disease in women, es- 
pecially in the unmarried and nulliparous. As a rule they are of slow 
growth, and frequently cease to grow after the menopause. They increase 
in size during menstruation and pregnancy; after parturition a tumor that 
was plainly evident almost completely disappears. 

Symptoms. — Haemorrhage, although not invariably present, is the most 
conspicuous symptom in fibroids of the uterus (menorrhagia or metror- 
rhagia). Pressure symptoms, such as pain, vesical irritation, rectal irrita- 
tion, and leucorrhcea, are usually complained of. Subserous fibroids may 
exist without giving rise to marked symptoms. Submucous fibroids, when 
expelled by uterine contractions, cause considerable pain and haemorrhage. 
When fibroids spring from the posterior part of the cervix, they may offer 



FIBROIDS AND CANCER OF THE UTERUS 



529 



an obstruction during parturition, but Nature's efforts are generally suc- 
cessful in elevating the tumor out of the pelvis. 

The diagnosis is made by taking into consideration the symptoms as 
described and by means of a physical examination (bimanual palpation). 

Differential Points.— Soft, cedematous tumors may simulate pregnancy, 
ovarian cysts, or inflammatory exudates. Carefully mapping out the 
body of the uterus and noting the nodular masses in intimate and close con- 
nection therewith will lead the experienced examiner to a correct interpreta- 
tion of the abnormal condition. Sounding the uterine cavity is permissible 
only when pregnancy is not in question and is usually unnecessary and often 
dangerous. 

Treatment. — Submucous fibroids may become polypoid and protrude 
from the uterine cavity. Their pedicle may be constricted and crushed or 
cut through, after which the vagina and uterine cavity should be firmly 
tamponed to prevent haemorrhage. Interstitial and subs«3rous fibroids in 
women near the menopause may be left to themselves if the symptoms are 
not urgent. Rest during the menstrual period is essential, and women so 
afflicted should wear an abdominal supporter. Pain may be controlled by 
the use of opium and belladonna suppositories and the hot water bag. 
Fluid extract of ergot and gossypium, 15 drops of each, given twice a day, 
will control haemorrhage in most cases. When palliative measures fail to 
bring about a reasonable degree of personal comfort, extirpation of the 
tumor or of the uterus plus the tumor is indicated in preference to oophor- 
ectomy, which was formerly done with a view to establishing an artificial 
menopause. The principal indication for radical operative interference is 
excessive haemorrhage. 

MALIGNANT NEW GROWTHS; SARCOMATA AND CARCINOMATA 

Cancer of the Cervix Uteri 

This occurs most frequently after the menopause, the classical symptoms 
being haemorrhage, pain, and a discharge. 

The differential diagnosis between cancer, syphilis, and tuberculosis of 
the cervix and endometrium involves an expert examination of the scrapings 
under the microscope and the employment of the therapeutic test for 
syphilis (potassium iodide), which should never be omitted. In cancer the 
tissues bleed at the slightest touch. 

The prognosis is unfavorable; patients afflicted with cancer of the 
cervix do not usually live more than three years. 

Treatment. — Complete and radical hysterectomy may prolong life. When 
the disease has extended to the cellular tissue or involves the bladder, 
rectum, or vagina, radical treatment need not be attempted. 

Palliative treatment consists in relieving pain, haemorrhage, and foul dis- 
charges. This can be accomplished more or less effectively by means of the 
actual cautery under anaesthesia, by the use of suppositories of opium and 
belladonna, by administering morphine subcutaneously, and by frequent 
douching with Labarraque's solution, 1 to 20, or other deodorizing and 
cleansing irrigations. 



530 



THE GENITOURINARY SYSTEM 



Cancer of the Body of the Uterus 

This occurs only in a small percentage of cases of uterine cancer. The 
symptoms are practically identical with those of fibroids, but the cachexia, 
even in the absence of profuse hemorrhage, is marked. Bimanual palpation 
reveals an enlarged uterus and a patulous cervix. Early and complete 
hysterectomy offers a more favorable prognosis than in cancer of the cervix. 

Malignant Tumors of the Ovary 

Malignant tumors of the ovary present the same symptoms and diag- 
nostic features as benign new growths in this region, but cachexia is more 
pronounced at an early stage and ascites is generally present. Their early 
operative removal is the only hope of prolonging life. 

Deciduoma malignum is a rare form of malignant degeneration of intra- 
uterine tissue taking its origin in remnants of chorionic villi or remnants of 
placental tissue retained in the uterus after labor or miscarriage. 

ABORTION; MISCARRIAGE 

The expulsion of the foetus in the first months of pregnancy from divers 
causes, such as syphilis, traumatism, pelvic tumors, acute infectious disease, 
etc. 

Symptoms. — Hemorrhage and pain are the principal symptoms. Ac- 
cording to the duration of pregnancy these symptoms will vary in intensity. 
When abortion occurs after the sixth month, we speak of premature labor. 

Prognosis. — In inevitable abortion the foetus is destroyed. The dangers 
to the mother are sepsis and bleeding. The remote dangers are subinvolu- 
tion of the uterus, endometritis, and sterility. 

Treatment. — The prophylactic management includes the correction of 
any known cause. If the patient has aborted a number of times, rest and 
the avoidance of sexual intercourse and of bicycle riding should be insisted 
upon. Antisyphilitic measures are indicated in that class of cases through- 
out the natural term of pregnancy. In threatened abortion the patient should 
rest in bed, and opium and belladonna in the form of rectal suppositories 
should be administered, or morphine given hypodermically. In unavoid- 
able abortion the cervix is patulous, and a light tamponade of the uterine 
cavity with iodoform gauze is readily accomplished by means of a hollow 
tampon carrier. Uterine contractions will expel the contents of the womb. 
In case of severe hsemorrhage tamponade of the vagina may be added to 
the uterine tamponade. In unavoidable abortion ergot may be given before 
and after the expulsion of the ovum. Retained placental tissue requires 
removal by means of curettage. In cases of labor and abortion antiseptic 
precautions should be taken as follows: For use on the vulva, the mixture 
consists of one drachm of chloride of calcium and two drachms of the 
U. S. P. (36 per cent) preparation of acetic acid to the quart of lukewarm 
water. For hand disinfection a solution of double this strength is em- 
ployed, following the usual cleansing with soap and water. After the 



ABORTION AND PUERPERAL SEPSIS 



531 



hands have been immersed in the solution for five minutes, they should 
be rinsed in plain water or a dilute lysol solution, as the chlorine which is 
set free will readily corrode instruments. 

PUERPERAL SEPSIS 

Puerperal infection is wound infection; therefore, it is the duty of the 
obstetrician to practise antiseptic midwifery and prevent puerperal fever. 
As soon as there is a rise of temperature after delivery, the cause of the 
fever should be determined if possible. Constipation, malaria, typhoid 
fever, mammary inflammation, and venous phlebitis external to the genital 
tract are to be excluded before we can suspect or establish the diagnosis of 
puerperal sepsis. 

Puerperal infection may be a local infection of the external genitals of 
minor importance, or it may be a serious affection of the internal genitals 
(uterus), or the whole system may be drawn into the morbid process. Re- 
sistance to puerperal infection, as in any other infection, lies in the lym- 
phatics and in the circulating blood, and a favorable or unfavorable termina- 
tion of the resulting systemic poisoning (septicaemia, toxaemia, bacteria?mia) 
depends upon the nature, quantity, and persistence of the septic material 
furnished by the morbid process and upon the natural resistance of the soil 
and circulating media reenforced by well directed therapeutic measures, 
which will do no harm. The great difficulty as regards the local manage- 
ment of puerperal sepsis is the difficulty of locating the lesion or the portal 
of entrance. 

Treatment of Puerperal Fever. — As soon as a fcetid discharge is detected, 
the vagina should be cleansed thoroughly with corrosive sublimate, 1 to 2,000, 
followed at once by boiled water irrigations. Such irrigations are effective 
when we have to deal with local lesions in the vagina and at the entrance 
to the genital tract. If we know that decomposing placental remnants are 
within the uterus, they should be removed by means of the finger. Intra- 
uterine douches are not as a rule indicated, except before and after intra- 
uterine manipulations. A patulous cervix a day or two after confinement 
indicates that the uterus is not empty. In such cases the cervix is so patulous 
as to admit one or two fingers readily. If it is known that the placenta has 
passed completely, the suspected retention of membranes alone does not 
as a rule call for active interference. In the mean time the patient has 
probably taken 10 grains each of quinine, calomel, and jalap, and in the 
event of the temperature not falling to normal, constipation and malarial 
fever may be ruled out. The agglutination tests for typhoid and para- 
typhoid fever are now to be employed and an examination of the urine 
(collected by catheter) should be made, having pyuria in mind, and an ex- 
amination of the throat and vulva for diphtheritic deposits. If the patient 
has the slightest sore throat or shows a pseudomembranous deposit at the 
vulva, or has in any way been exposed to diphtheritic infection, 2,000 units 
of diphtheria antitoxine should be given subcutaneously at once. Acute 
miliary tuberculosis must also be thought of in puerperal cases. When 
by exclusion the diagnosis of puerperal sepsis is established, the question of 
intrauterine treatment will present itself. 



532 



THE GENITOURINARY SYSTEM 



Irrigation and drainage of the uterine cavity should be done in the fol- 
lowing manner : A solution of lysol (from 1 to 3 per cent) is used for flushing 
the uterus. The fluid is introduced by means of the uterine catheter. 
Dilatation is unnecessary, as the os is patulous on the second or third day 
following labor in all cases in which placental remnants are retained. In this 
class of cases careful scraping with a blunt curette may be indicated and 
will do no harm. Owing to the difficulty of locating the source of infection, 
severe surgical measures, such as the removal of the entire uterus, are rarely 
indicated and should not be attempted without a consultation. 

The various sequelae of septic infection, such as bedsores, pneumonia, 
pleurisy, phlebitis, arthritis, etc., will require the attention and treatment 
which such complications call for. 



CHAPTER XX 



OSSEOUS, MUSCULAR AND ARTICULAR SYSTEM, 
AND ORTHOPEDIC MEMORANDA 

DISEASES OF BONE 

Synopsis: General Remarks. — Remarks on the Pathology of Inflammation in Bone. — Acute 
Inflammation of Bone. — Osteoperiostitis, Osteomyelitis, Osteoepiphysitis, Pyaemic Bone 
Abscess. — Chronic Inflammation of Bone. — Tuberculous Osteoperiostitis, Tuberculous 
Osteomyelitis, Bone Syphilis, Actinomycosis of Bone, Tumors of Bone, Hypertrophy 
of Bone, Atrophy of Bone, Osteitis Deformans, Leontiasis Ossea, Osteomalacia. 

GENERAL REMARKS 

Aside from injuries and congenital or acquired anomalies of form and of 
tumor formation, we observe in bone, muscles and joints a variety of diseases 
due to simple or neuropathic malnutrition and to acute and chronic infection. 

Infection usually takes place through the circulation. We may have a 
rheumatic, gonorrheal, syphilitic, tuberculous, or malarial infection of these 
tissues, or other toxic diseases, such as influenza, typhoid fever, scarlatina, 
measles, variola, diphtheria, etc., may be underlying factors. The strepto- 
coccus, but particularly the staphylococcus invasion through the skin or 
mucosa, is frequently the cause of osteomyelitis and other inflammatory 
conditions. The primary lesion may be a pustule, an eczematous patch, 
a stomatitis, etc. Acute inflammations may subside or terminate in serous 
or purulent effusion and necrosis. Chronic inflammations, simple, syphilitic, 
tuberculous, actinomycotic, etc., are usually accompanied by plastic deposits. 

As the bones and muscles govern locomotion, the subject of posture and 
gait demands a few words. A patient in bed may be in the dorsal position 
and immobile on account of pain. The legs may be drawn up, he may 
favor one side, or he may exhibit restlessness or show a position peculiar 
to paralysis and atrophy. The gait may be ataxic, spastic, waddling, or 
halting. The movements may be incoordinate and trembling. In the 
prone position, when the body rests upon the head and heels, the trunk being 
arched, we speak of opisthotonus. In dyspncea and orthopncea the patient 
sits upright with the hands and elbows placed in such a way as to support 
the head and thorax, in order to facilitate breathing. 

Remarks on the Pathology of Inflammation in Bone 

According to the location of the point of least resistance, the pathological 
process may begin in the medulla, the bone proper, or the periosteum. As 
these are intimately associated, we seldom observe a pure osteitis, periostitis, 

533 



534 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



or myelitis, but usually an inflammation including two of the contiguous 
parts. 

If the inflammatory process begins in the periosteum we notice swell- 
ing, increase of vascularity, and a tendency of the periosteum to sepa- 
rate from the bone. This inflammation may recede and the part involved 
resume its normal condition, or the process may go on to suppuration 
and the pus burrow under the periosteum for a greater or less distance. 
Healing may begin as soon as this abscess is evacuated, which may result 
spontaneously through the soft parts, or be hastened by surgical means. 
Usually, if the process goes on to suppuration, the portion of bone denuded 
becomes necrotic, and healing is delayed until this piece of bone separates 
and is exfoliated or surgically removed. 

Should the process begin in the bone proper, there is first increased 
vascularity within and around the focus of disease, with the' formation of 
capillary loops. Absorption and erosion take place along the walls of the 
Haversian canals, a rarefying osteitis. At the same time new bone begins 
to form underneath the periosteum, as well as in the medulla, causing an 
enlargement of the bone at that point. Under favorable conditions the in- 
flammatory exudate is absorbed. If, however, the irritation is of long dura- 
tion, the bone remains larger and harder than before (osteosclerosis). This 
new bone may become as hard as ivory. Should the inflammatory process 
so press upon the vessels as to obliterate them, necrosis of a greater or 
smaller area takes place. If the process goes on to suppuration, particularly 
around the dead piece of bone, we have resulting a chronic abscess, a con- 
dition particularly seen in tuberculosis of the bone. In a very acute and 
particularly virulent inflammation, with compression of the vessels, there 
may be an acute necrosis with abscess formation which does not heal until 
the inflammatory products and necrosed bone are evacuated spontaneously 
or by surgical procedure. 

In osteomyelitis the inflammation begins in the medulla from an infec- 
tion carried to this point of least resistance by the circulation. In acute 
forms a serious and widespread destruction with often fatal results may occur. 
The process may remain local or involve the whole shaft of a long bone 
between the epiphyseal margins. The process probably seldom resolves 
before producing sufficient pressure in the hard and resistant tissue to cause 
necrosis. Embolic processes in various organs may occur. 

With the formation of an abscess within the medullary cavity, if no 
surgical treatment intervenes, and the patient survives, new bone is formed 
beneath the periosteum, which encloses the old bone tissue like a shell. 
The process now becomes chronic; the old bone necroses, the pus burrows 
and finally escapes through cloacae in the new bone, breaking through the 
periosteum to form an abscess in the soft parts. This in turn presses 
farther, burrowing and undermining until it reaches the surface, where 
its contents are discharged. The old necrosed bone is partly absorbed, 
and may be broken up into smaller sequestra to be discharged through the 
cloacae. Healing cannot take place until all the dead bone has been ex- 
foliated, and if Nature unassisted manages the case, the process may last for 
years with alternating opening and closing of the sinuses. 

In subperiosteal hemorrhage the extravasated blood, if it is not infected, 



ACUTE INFECTIOUS OSTEOMYELITIS 



535 



is slowly absorbed without apparent harm to bone or to periosteum, If 
it becomes infected, subperiosteal abscess follows. 

Examination of bony structures in particular is facilitated by means of 
the Rontgen rays (fluoroscope and shadowgraph). 

The general principles of treatment in this group of ailments consist 
mainly in the application of rest, elevation, traction, extension, immobiliza- 
tion, and elastic compression together with hydrotherapy, massage, vibratory 
massage and stimulation, movement cure, the application of dry hot air, 
and specific and symptomatic medication. The details of surgical treat- 
ment will be found in the books on surgery. 

ACUTE BONE INFLAMMATION 

Osteoperiostitis 

Simple Osteoperiostitis. — Symptoms. ■ — In a simple case, from injury 
and a mild infection, there are pain and swelling, with or without slight 
redness and heat. There is slight or no elevation of temperature, and 
little or no systemic disturbance. 

Treatment. — Antisyphilitic remedies are indicated in suspected cases, 
and for the others the recumbent position, an ice bag, or wet dressings. 
A subperiosteal haemorrhage is best absorbed with the assistance of heat, 
pressure, massage, and vibration. 

Purulent Osteoperiostitis. — If the process continues in spite of this treat- 
ment, or the infection is more severe, virulent, or diffuse, or the haematoma 
becomes infected, we observe the systemic signs of pus— fever, with or without 
chills, with more or less severe localized pain, redness, tenderness, and later 
fluctuation. 

The treatment is surgical. In the severe cases with urgent general 
symptoms an early exploratory puncture or incision is indicated. 

Acute Infectious Osteomyelitis 

Symptoms. — There is a chill, or rigor, followed by high fever. The 
local symptoms may be accompanied by a developing severe septic intoxi- 
cation, stupor, and delirium. Pain, gnawing or boring, is an early and 
persistent symptom. It may not be distinctly felt at one point, but may 
extend through the whole shaft of a bone and even into the neighboring 
joints. It is worse at night, increasing with the accumulation of the ex- 
udate and diminishing with perforation. In multiple osteomyelitis pain 
may not be a prominent symptom. Tenderness on pressure is severe. 
Swelling and redness are not marked until the periosteum becomes involved. 
QMema from thrombophlebitis and enlargement of superficial veins may 
be present. When perforation takes place and pus accumulates in the 
soft parts, we observe prominent redness, swelling, and fluctuation. The 
limb and neighboring joints cannot be moved without causing pain. 
Spontaneous fracture, separation of the epiphyses, or a synovitis of the 
adjacent joints may occur earlier or later in the disease. 

The diagnosis is to be made by the deep, boring, gnawing character of 
the pain and by its not being most intense in the joint, although frequently 
35 



536 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



very near it, at the epiphysis. It is sometimes mistaken for sciatica or for 
rheumatism, particularly in young children. 
The treatment is surgical. 

Acute Epiphysitis 

This occurs in infants and young children as a result of pyogenic bacterial 
infection. It resembles osteomyelitis in symptoms, except that it has a 
tendency to involve the adjacent joint rather than the shaft of the bone, 
giving rise to a suppurative arthritis. In young infants it may take its ori- 
gin from an infection of the umbilical cord; in older children from an acute 
amygdalitis, diphtheria, scarlet fever, scurvy, or other infectious disease. 

Symptoms. — The tissues over an epiphysis become swollen and painful 
and the limb is not moved. The child is feverish and restless, showing a 
systemic infection. The joint soon presents the appearance of an acute 
suppurative arthritis, or an abscess may point near a joint. If an abscess 
points toward and penetrates a joint, rapid absorption of the cartilage 
occurs and the pus reaches the surface. Healing takes place often with very 
little impairment of the joint function, but with subsequent retarded growth. 

Treatment. — The prophylactic management of scurvy and other infec- 
tions predisposing to acute epiphysitis is of prime importance. Rest and 
elevation of the affected part are indicated. After the formation of pus the 
treatment is surgical. 

Pyosmic Abscess of Bone 

If there is a localized process instead of an osteomyelitis, due to an in- 
fectious embolus, there results a suppurative osteoperiostitis with abscess 
formation. The treatment is described under that head. 

CHRONIC INFLAMMATION OF BONE 

Tuberculosis of Bone 

Primary general tuberculosis of bone is very rare and exists only as an 
accompaniment of general tuberculosis. 

Localized tuberculosis is usually seen in the cancellous tissues of the 
carpus, the phalanges, the bodies of the vertebrae, and the ends of long bones. 
In this latter position the joint is frequently involved. The pathological 
process is very similar to that of other forms of bone inflammation, except 
that it is more chronic and shows the characteristic caseation and softening. 
We observe, therefore, tuberculous osteoperiostitis , tuberculous osteomyelitis, 
and tuberculous bone abscess. 

Tuberculous osteoperiostitis is very common and may be seen in almost 
every bone of the body. Extensive destruction may occur, and the process 
go on to abscess formation. 

Symptoms. — Pain and tenderness are not marked, and usually the first 
symptom to attract the attention of the patient is swelling. Frequently 
before this develops there are signs of systemic disease or other tuberculous 
symptoms. 

Treatment. — General antituberculous and tonic treatment should be 



TUBERCULOSIS OF BONE 



537 



pushed, and the local trouble treated by rest, by artificial hyperemia 
(Bier's treatment), or by surgical interference. (See Joint Tuberculosis.) 

Tuberculous Osteomyelitis. — This may affect the long, short, or flat 
bones. It is more often seen in young adults, and the epiphyseal margins 
are usually the starting points. An hereditary predisposition to tuberculosis 
is generally recognized as being present in many cases. Impaired nutrition 
following some systemic infection, such as scarlet fever, measles, enteritis, 
typhoid fever, or pneumonia, 
predisposes to tuberculous dis- 
ease. 

At the places of infection we 
see first a rarefying osteitis, then 
the periosteum thickens and 
granulation tissue forms. A 
sequestrum may form. The 
granulation tissue may become 
caseous, or it may liquefy and 
produce the so called tubercu- 
lous abscess consisting of de- 
generated cells, curdy, cheesy 
material, and bony detritus. It 
looks like pus, but is not unless 
it has become infected by pyo- 
genic organisms from without or 
through the blood. It opens 

into a joint Or on to the Surface, FlG ' 167. -Tuberculosis of Os Calcis. 

leaving a sinus lined by tuber- 
culous granulations. At the bottom of this sinus, by means of a probe, we 
can usually detect denuded, necrosed, or soft bone. The sinus may con- 
tinue discharging for months or years if not treated, or an absorption or 
calcification with the formation of sclerosed bone may take place. 

Symptoms. — Spontaneous moderate pain or tenderness is the most 
important symptom, but at first the disease is very difficult to recognize. 
The progress is very slow, and we seldom make a diagnosis until localized 
pain or an external swelling develops. Impairment of function and atrophy 
of the muscles from disuse are present. (Edema and finally fluctuation 
occur over the swelling, and sometimes redness, but the latter is usually 
absent and we observe the characteristic white swelling. Fever is often 
very slight and sometimes absent unless there is a mixed infection. When 
the abscess breaks or is incised, we see the tuberculous contents. 

Diagnosis. — It is only in cases of chronic osteomyelitis from other causes 
that we are likely to be mistaken in diagnosis. If we remember that tuber- 
culous osteomyelitis is found most often in young adults, is slow in progress, 
apt to involve the articular ends of long bones, and to form a limited area 
of swelling with but moderate tenderness on pressure, we usually make no 
mistake. 

The prognosis, with the best of surroundings, as well as with the best of 
treatment, general and local, is moderately good. 

Treatment. — Hygienic and tonic management and surgical treatment. 




538 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



Syphilis oj Bone 

Syphilitic Periostitis. — In the early stages of syphilis we may observe the 
small periosteal nodes, most usual on the superficial aspect of the tibia, 




Fig. 168. — Tuberculous Focus in Tibia, Healed. Skiagram (Besser). 



clavicles, sternum, ribs, and skull. They are very painful, particularly at 
night, as are all syphilitic bone affections. They are also tender to the 
touch. Amelioration is obtained by instituting antisyphilitic treatment. In 
hereditary syphilis, or in the later stages of acquired syphilis, frequently 
enough periostitis of one of the long bones occurs, the anterior margin of 
the tibia being a favorite location. It is generally accompanied by a chronic 

osteitis, and may result in a syphi- 
litic osteosclerosis or gumma. 

Syphilitic Osteitis. — Without the 
accompanying periostitis, we may 
observe an osteosclerosis of many 
bones at the same time. It pro- 
duces more or less symmetrical en- 
largement of the bone involved. 

Syphilitic gummata may form 
under the periosteum and at the 
same time may be associated with 
periosteal nodes and osteosclerosis. 

Fig. 169. — Tuberculous Knee Disease. There may be a proliferation of 

granulation tissue, shutting off the 
circulation completely, causing syphilitic necrosis resembling an ulcerative 
process in the soft parts, and we then term it syphilitic caries oj bone. 
This is most often seen on the sternum or skull. The distinctive feature 
of a gumma of bone is an area of fluctuation in the tumor, which, un- 




BONE SYPHILIS AND BONE TUMORS 



539 



treated, may break down and discharge a thin watery fluid. It is prone to 
secondary infection, which makes an ugly, deep, and intractable ulcer. It 
is likely to undermine the surrounding tissues. 

Hereditary syphilis of bone does not differ much from the acquired form. 
The lesions are more likely to be multiple and affect the long bones. As a 
rule it is less painful and less 
amenable to treatment. 

Syphilitic dactylitis is both 
hereditary and acquired, in the 
shape of an osteoperiostitis of 
the phalanges of the fingers 
with an involvement of con- 
nective tissue and symmetrical 
enlargement. 

Treatment. — The treatment 
of syphilis of bone is systemic 
("mixed treatment"). Some- 
times advanced obstinate cases 
with severe pain demand surgi- 
cal help. Care should be ob- 
served not to create a mixed 
infection of an open lesion, as it 
thus becomes more difficult to 
handle. 

Actinomycosis of Bone 

This rather rare infection of 
bone is usually seen in the 
maxilla?, where it apparently 
gains access through carious 
teeth. Marked swelling and a 

little pain are the usual symptoms. Abscesses may form, containing the 
little hard, white characteristic nodules. Under the microscope we recog- 
nize the ray fungus. 

The treatment is systemic (potassium iodide) and surgical. 




Fig. 170. — Tuberculous Disease of Elbow. 



Benign Tumors of Bone 

Tumors of bone take their names as a rule from the tissue from which 
they spring. 

Cysts. — Non-malignant cysts are very rare. Those of the teeth are 
described as odontomas. Those of the long bones cause enlargement and a 
thinning of the overlying bony tissue. Exploratory puncture or a shadow- 
graph establishes the diagnosis, and the treatment is surgical. 

Osteomata are tumors composed of bony tissue. If they grow from the 
surface of a bone, they are called exostoses. Their structure is the same as 
that of the bone from which they spring, with a regular arrangement of 
the cells. Cartilaginous growths from the epiphyseal ends of long bones, 



540 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



or from tendons at their attachments, subungual growths, and inflammatory 
growths may become bony in character and are called exostoses, but they are 
not true bony growths. 

Compact osteomata, structurally, are the same as normal compact bone, 
and although they may grow from any bone, they are most often found in the 
frontal sinus, the external and internal auditory meatus, and the mastoid. 

Cancellous osteomata resemble cancellous bone and may be sessile or 
pedunculated. 

Although osteomata may originate in any bone, they are found most 
often connected with the phalanges, femur, tibia, humerus, vertebrae, and 
flat bones. 

Bony tumors occur rarely as independent neoplasms in the breast, 
testicle, or brain — as ossifications, however, not true bone tumors. 

Odontomata, or teeth tumors, are named from the part of the tooth from 
which they arise. 

Epithelial odontomas are encapsulated tumors, more often in the man- 
dible, and are made up of a congeries of variously shaped cysts. 

Follicular odontomas are dentigerous cysts, usually associated with the 
permanent molars. They may become very large and produce great de- 
formity. The cyst wall is calcareous, occasionally bony, and it usually 
encloses a viscid fluid and a tooth that has not emerged, which may be fixed 
or loose and inverted. 

Fibrous Odontomas. — The capsule surrounding a tooth before its erup- 
tion may become thickened, preventing eruption of the tooth, and form a 
new growth. 

Compound follicular odontomas are larger and contain more than one 
tooth, fragments or denticles. 

Radicular odontomas are very rare. They are due to abnormal growth 
of the roots of the teeth, which push the crown before them. The enamel 
is not involved. 

Composite odontomas are new bony growths composed of a disordered 
conglomeration of all the tissues of the teeth. 

Fibromata of bone usually develop from the periosteum, and are most 
often found attached to the jaws, the palate, or the base of the skull. 

Chondromata are really cartilaginous in nature, but may grow from 
normal bone, as well as from normal cartilage. True chondromata may 
arise also from the medullary cavity. If they originate in other tissues, 
they often show malignancy. 

Treatment of Benign Tumors of the Bone. — If any is required, it is 
surgical. 

Bone rickets is discussed in the section on Paediatrics. 

Malignant Tumors of Bone 

Sarcomata. — A primary malignant tumor of bone is always one of the 
varieties of sarcoma. Its structure is the same as it is when originating 
from other tissues. In bone it may be central or peripheral in origin. The 
malignancy of bone sarcoma is proved by its tendency to recur after removal, 
and to metastasis, especially in the lungs. 



MALIGNANT TUMORS OF BONE 



541 



The degree of malignancy differs greatly according to the situation of 
the growth and the nature of the cell. Giant cells predominate in the least 
malignant, the myeloid, and the periosteal spindle celled sarcoma is the most 
malignant. 

Their favorite locations are the jaws and the articular extremities of 
the long bones. The lower end of the femur and the upper end of the tibia 
are the most frequently involved, probably because this region is most 
exposed to injury, which seems a predisposing factor to their development. 
The young adult is most often affected, although no age is exempt. Their 
growth is very rapid, particularly in periosteal tumors. Pulsation is of 
frequent occurrence in the central tumors of the long bones. Spontaneous 
fracture of the bone at the seat of growth may occur. Pain is a prominent 
symptom. The size may be enormous, but it is no criterion as to the prob- 
ability of infection of other parts of the body. 

The diagnosis is made by the history of the rate of growth, sarcoma 
growing very rapidly, from the fact that in sarcoma there is a difference in 
consistence in different parts of the tumor, and from the presence of pain. 
It is sometimes difficult to distinguish between a pulsating sarcoma and an 
aneurysm. We are aided in recognizing a sarcoma by its location, by the 
presence of bony plates on the surface, by its ill defined outlines and com- 
paratively feeble impulse, and by the absence of any change in the arteries 
below the tumor. The radiograph is of very great value. 

The treatment is surgical. An operation should be early and radical. 

Carcinomata, as primary growths, are probably unknown. They are 
not uncommon as metastases or as complications by extension. 

Hypertrophy of bone is rarely seen unassociated with osteosclerosis. 
Occasionally, however, a congenital enlargement of a whole limb has been 
seen. Osteosclerosis and osteomyelitis are generally the cause of enlarge- 
ment of bones. The term osteoporosis has been applied to this condition. 

Atrophy of bone is more frequently seen, and usually results from defec- 
tive nutrition and diminished function. The bone becomes more porous and 
the medullary cavity and cancellous tissue increase in size and are filled 
with fat. The cortex wastes. It is seen at any age, but most often in old 
people. In infantile paralysis, when the bones of one or more limbs remain 
wasted, we see this atrophy. We also see it after fractures, when function 
has been suspended for some time. 

Treatment. — Various means to improve nutrition, passive motion, mas- 
sage, and Esmarch's bandage, applied at intervals to produce hyperemia, 
may be tried. In old age little can be done (see Bier's method, under 
Tuberculous Joints). 

Osteitis deformans is a somewhat rare disease, characterized by a change 
in the size, shape, and direction of the diseased bones. It begins in middle 
life or later. The bones enlarge, soften, and gradually become curved, pre- 
senting considerable deformity. The long bones of the lower extremity or 
those of the skull are usually involved first. 

The symptoms are not marked. There is some indefinite pain of the 
lower part of the spine and the lower limbs, which is generally attributed to 
rheumatism. The general health is usually unaffected. 



542 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



Treatment seems of no benefit. 

Leontiasis ossea is a rare bone disease characterized by a gradual enlarge- 
ment, a hyperostosis, of the facial and cranial bones, leading to great de- 
formity and causing pain by pressure. 

The treatment is surgical, simply to relieve pain. 

Injuries, Fractures, and Dislocations of Bones. — All bones are subject 
to injuries, direct or indirect, which may result in fracture or dislocation. 
These lesions are described in books on surgery. 

Osteomalacia (Mollities Ossiwri) 

Osteomalacia is a disease in which there is pain in the bones, with their 
gradual softening, subsequent bending, and liability to spontaneous fracture. 

.(Etiology. — The cause of the disease is unknown. It is a disease of 
adults, being exceedingly rare in children, usually occurring between the 

ages of twenty-five and forty and of 
far greater frequency in women than 
in men. It is more frequent in cer- 
tain sections of country than in 
others, the regions where it is often- 
est seen being along the Rhine, in 
Westphalia, in eastern Flanders, and 
in northern Italy. Osteomalacia 
appears to have some relation to 
ovarian secretion. 

Childbearing is certainly an ex- 
citing cause in many cases, as the 
first signs and exacerbations date 
from and appear during pregnancy. 

Symptoms. — The first symptom 
usually noticed is a deep seated pain 
in the sacral region, in the back of 
the thighs, or in the neck. It is 

Fig. 171.— Osteomalacia Deformity. usually called rheumatic. The next 

change is weakness in the lower ex- 
tremities, so pronounced that the patient walks peculiarly and desires 
help. The pains continue and may be very severe. The deformities soon 
present themselves, or a fracture occurs. A difficult labor may be the 
first symptom calling attention to the bony condition. 

When the disease has advanced, the deformities may be very marked, 
affecting the whole skeleton. The spine, increasing the normal curves, 
assumes a marked kyphosis, or the curves may be in the opposite direction. 
The head approaches the sternum more and more, making the patient appear 
shorter than he is in reality. The ribs are pressed in laterally and protruded 
at the sternum, which is pushed forward and often fractured at several 
places. 

The shape of the pelvis, not very apparent without careful examination, 
may become so changed as absolutely to prevent parturition. The sacrum 
is carried down by the weight from above and the ilia and ischia are pressed 




OSTEOMALACIA (MOLLITIES OSS1UM) 



543 



inward by the heads of the femur, which also press upward in the acetabula 
and cause the pubic symphysis to be thrust forward like a beak. This de- 
formity makes the peculiar gait uncertain, tottering, and characterized by 
short, painful steps, the lower limb and pelvis being jerked forward as if 
in one piece. The arms, legs, and thighs are bent or fractured in various 
ways, but the patient has usually become bedridden before she is much 
deformed. The bones of the head are seldom affected. The teeth may become 
loosened. The viscera usually perform their functions, although the bony 
deformities may press upon them. The lungs may be compressed, and 
dyspnoea, feeble breathing, and pneumonia be the result. The urine some- 
times contains albumin. It is said by some writers to contain an excess of 
calcium salts. 

Course. — The course of the disease is chronic. In some the different 
stages follow rapidly, and the patient is soon obliged to go to bed and re- 
main there. It may then run its course in a year. In others progress is 
noticeable only in the pelvis and then only during pregnancies, the disease 
remaining stationary or making only very slight progress at other times. 
Some live for many years with very slow advances of the disease, and are 
not obliged to remain in bed. 

The prognosis is bad, as recovery is exceptional. The patients die 
from the general debility, or more often from the effects of the pressure on 
the lungs, or from pneumonia. 

The diagnosis is not difficult in well developed cases. The locality, the 
examination of the pelvis, the peculiar hobbling gait, and its association 
with pregnancy are the salient points of distinction. Rickets is a chil- 
dren's disease with enlargement of the epiphyses. Children are very rarely 
affected with osteomalacia and the epiphyses are not enlarged. It is said 
that diffuse carcinosis of the bones may produce similar symptoms and 
deformities. 

Treatment. — In the severe cases therapeutics seems of no avail. In the 
beginning there may be marked improvement by hygienic methods, good 
air, proper food, and tonics. Warm baths, with or without salt, are appro- 
priate. Iron and phosphorus appear indicated. 

At the meeting of the Surgical Congress in Berlin in 1902, three cases of 
non-puerperal osteomalacia were reported cured by castration. 



CHAPTER XXI 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM — Continued 

DISEASES OF JOINTS AND BURS./E 

Synopsis: General Remarks. — Sprains. — Synovitis, Acute, Purulent, Chronic. — Arthritis, 
Acute, Septic, and Gonorrhceal. — Acute Articular Rheumatism in adults and children. 
— Arthritis Deformans, Differential Diagnosis between Arthritis Deformans and Chronic 
Rheumatism. — Tuberculosis of the Joints. — Loose Bodies in the Joints. — Displacement 
of the Semilunar Cartilages. — Neoplasms of Joints. — Neuroses of Joints. — Neuralgic 
Conditions. — Neuropathic Arthritis. — Bursitis. 

GENERAL REMARKS 

Joints in all parts of the body, but principally those most exposed, are 
liable to injuries, such as wounds, contusions, sprains, dislocations, and 
fractures. Any injury, however slight, may be serious in its results, 
owing to a disturbance of the exquisite mechanism of a joint. There may 
be laceration of ligaments and synovial membrane, detachment of cartilages, 
or injury to the articular ends of the bones. The joints may be distended 
with blood. A slight bruise may result in rapid and complete recovery 
in a healthy subject, while in one who is in poor general health, or one suffer- 
ing from tuberculosis, the injury may be the exciting cause of the develop- 
ment of a tuberculous joint, abscess, necrosis of the ends of the bone, or 
even sarcoma. In elderly people even the slightest injury may result in a 
serious arthritis and ankylosis. 

Dislocation of joints may be of traumatic origin or may be spontaneous 
or habitual. Reposition of a recent dislocation is accomplished with and 
without general anaesthesia. 

Wounds of joints, especially penetrating wounds, frequently carry infec- 
tious material into the joint, causing acute suppurative arthritis, a very 
grave affection which rarely heals without ankylosis and not infrequently 
results in the loss of limb and sometimes of life. 

Fractures into a joint frequently heal with impairment of function. 

Symptoms of joint injuries in general are pain, tenderness, swelling, 
and more or less disturbance of function. The pain may not be severe, 
but upon trying to use the joint, it may be intense. There may be an 
effusion into the joint. 

Treatment. — Owing to the disastrous results which may follow even a 
slight injury to a joint, it should receive the most careful attention. We 
should omit no means of diagnosis, such as the Rontgen rays and general 

544 



SPRAINS, SYNOVITIS, ARTHRITIS 



545 



anaesthesia, to exclude fractures and lacerations. If no complications are 
found, we should put the joint at rest by means of splints, sandbags, or pos- 
ture in bed. Pressure, ice, or heat may ease the pain. After diminution 
of swelling and absorption of effusion, that is, several weeks after the injury, 
massage, vibration, and passive motion should be employed. Contusions 
may impair the function for months. 

Wounds of joints with infection or suppuration demand surgical treat- 
ment. 

CLINICAL VARIETIES OF JOINT LESIONS 

Sprains 

A sprain is a violent wrenching or twisting of a joint, producing stretch- 
ing or laceration of the capsule, synovial membrane, ligaments, tendons, 
or periosteum, accompanied by effusion of blood or serum into the joint 
and surrounding tissues, and 
is generally the result of in- 
direct violence. There may 
be all degrees of severity, 
from simple stretching to 
tearing and displacing of 
tendons and muscle fibres. 
Where the insertion of a 
ligament or tendon is 
wrenched away, carrying 
with it a small piece of bone, 
it is called a sprain fracture. 

The symptoms are those 
of a contusion, but are more 
severe. At the time of the 
injury the pain is very se- 
vere, and may result in syn- 
cope. Ecchymosis is usual. 

Diagnosis. — Use the 
above described methods 

for examination to exclude fracture. Be careful to diagnosticate the sep- 
aration of an epiphysis in children. 

Treatment. — In the simple cases we may need merely a supporting band- 
age or strapping, and later daily massage. In the more severe cases, place 
the joint at complete rest by means of splints or compression bandages. 
Anodyne liniments may be useful. Plaster of Paris or water glass bandages, 
after the swelling subsides, are valuable for immobilization, as are strips of 
adhesive plaster arranged to press, immobilize, and massage all at the same 
time. This massage is accomplished by having the patient use the joint 
after the application of the adhesive plaster. Fixation by adhesive strips 
allows of a certain amount of friction between the skin and the deeper parts. 
These measures tend to aid in the absorption of the fluid, but if they do not, 
it should be aspirated. Later we make use of passive motion, massage, 
vibratory stimulation, and hot air treatment. Forcible breaking up of 
adhesions under anaesthesia may be required in some cases. 




Fig. 172. — Strapping the Knee (Dr. G. H. Semken). 



546 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



SYNOVITIS 

Acute Synovitis. — This is an inflammation of the lining membrane of a 
joint, and arises from overuse, injury, systemic infection, tuberculosis, gout, 
or rheumatism, or in the course of other infectious diseases. The process 
may excite a very slight exudation with simple flakes of fibrin, as in dry 
synovitis, which results either in complete resolution or in organization with 
adhesion; or there may be considerable effusion, thin, watery, flocculent, or 
hsemorrhagic. The tendency of the fluid is to become turbid from the fibrin 
and blood elements. Absorption may take place, leaving normal conditions, 
or more or less fluid may remain for some time, constituting the chronic 
condition called hydrops articuli, or hydrarthrosis. In the dry form there 
may be crepitation upon moving the joint, and the pain thus elicited is 
out of proportion to the severity of the inflammation. 

Symptoms. — Swelling, heat, tenderness pain, sometimes redness, and 
later fluctuation. The general temperature may be elevated. The limb 
is usually held between flexion and extension in the effort to limit pain. 

Treatment. — If resolution does not take place with rest, immobilization, 
and cold, the joint may need surgical attention. Treat the gout, rheuma- 
tism, malarial disease, and underlying systemic diseases. 

Purulent Synovitis. — If the effusion becomes infected from without or 
through the blood, we observe the systemic signs of pus. If pus develops, 
the joint must be incised and drained. 

Chronic Synovitis. — In the chronic form, resulting from an unresolved 
acute process or from some slowly developing factor, there is usually a wider 
involvement of the joint structure, making it more properly an arthritis, 
under which head it will be described. 

ARTHRITIS 

All the tissues in and around a joint may be involved in an arthritis. 
It may develop from a synovitis, from an injury, or from specific microbes, 
such as those of gonorrhoea, typhoid fever, scarlet fever, smallpox, dysentery, 
or other infectious diseases, from gout, rheumatism, or syphilis, or from 
diseases of the spinal cord. 

Acute Arthritis. — An acute infective arthritis is due to the entrance of 
pathogenic organisms into a joint. An abscess sometimes forms, but the 
process usually subsides without suppuration. The latter course is more 
common in the forms complicating the infectious fevers. Cases of infective 
arthritis have many points in common with cases of septic arthritis or joint 
abscess. The joint is painful, tender, red, and swollen, and yet does not go 
on to suppuration. 

Treatment. — Cooling and anodyne lotions, ice, immobilization, cotton 
wadding, and splints. The disease of which arthritis is a complication 
should have its proper treatment. 

Acute Septic Arthritis or Abscess of the Joints. — This results from the 
infection of a joint with pyogenic bacteria through a penetrating wound, 
by extension from bone or soft parts, or as a pysemic focus. We thus ob- 



ACUTE ARTICULAR RHEUMATISM; RHEUMATIC FEVER 547 



serve a purulent synovitis with a breaking down or separation of the ar- 
ticular cartilages. The ligaments may also become softened and eroded. 

Symptoms. — The joint becomes red, hot, swollen, cedematous, tender, 
and very painful, particularly upon motion and at night. Some fluctuation 
appears, and the joint becomes flexed. If there is a preceding pyaemia, 
we observe its constitutional symptoms first, with many slight local symp- 
toms. If not, constitutional symptoms soon develop with an initial chill 
or chilliness, then fever, sometimes as high as 106° F. The pulse becomes 
rapid, and the patients present the severe general symptoms of toxic in- 
fection, from which they may die in three or four days. A number of joints 
are usually involved. 

The prognosis depends upon the general capability of resistance and the 
early treatment by free incision and drainage. As a result of destruction of 
the different parts of the articulation, there is a useless or only a partially 
useful joint remaining. As a rule complete ankylosis results. Death may 
occur from the severity of the infection. In pyaemia the prognosis is bad. 

The treatment is surgical by incision and drainage. 

Gonorrhceal arthritis in its acute stage is likely to arise during the 
course of an acute or chronic urethritis due to gonococci with and without 
other pyogenic bacteria. The knee and ankle are most commonly in- 
volved, although other joints may be. It is exceptional to have more than 
one joint infected by gonococci. 

Symptoms. — The joint becomes swollen, red, hot, tender, and very pain- 
ful. It assumes a flexed position to relieve intraarticular pressure. The 
pulse and temperature are usually affected. Suppuration occasionally 
occurs, and then there is probably a mixed infection. In the subacute and 
chronic stages, there may be some effusion into the joint. The inflammation 
usually becomes chronic, and many adhesions form in the joint, resulting 
in more or less ankylosis. 

Treatment. — The urethritis should be treated. Locally, hot and cold 
applications are indicated. Immobilization by plaster of Paris splints has 
proved very effectual. Hot air treatments are very helpful in the subacute 
and chronic conditions. In suppurative cases incision and drainage are 
indicated. In order to reestablish the mobility of joints, active and passive 
motion, massage, and vibration should be employed. Bier's treatment 
has given excellent results (see Tuberculosis of Joints). 

JOINT AFFECTIONS IN BLEEDERS; SCURVY AND GOUT 

The joint affections with bleeders are described under Haemophilia. 
Scurvy and Joint Affections (see Scurvy) . 
Gouty joints are described under Gout. 

ACUTE ARTICULAR RHEUMATISM; RHEUMATIC FEVER 

This is an acute infectious synovitis characterized by pain in joints, 
tendon sheaths, and bursas, with a tendency to invade serous membranes, 
endocardium, pericardium, pia mater, pleura, and peritonaeum. 

The joint shows an exudation of serum, rarely of pus and fibrin. An 
inflammation of the tonsils, pharynx, larynx, and iris is sometimes present. 



548 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



The portal of entrance for the rheumatic infection is probably the naso- 
pharynx. Gonorrhoaal rheumatism finds its way into the system through 
the genital tract. 

Prevalence. — It is seen in all climates. No race is exempt. It is a dis- 
ease of early adolescence and early manhood and womanhood, the greatest 
liability to the disease being between the ages of ten and thirty. 

^Etiology. — While rheumatism is undoubtedly an infectious disease, the 
microorganism of the disease has not yet been positively accepted, although 
several investigators have found a coccus which they think is pathognomonic 
of this disease. 

Exposure to cold and wet seems to act as an exciting cause. A person who 
for a long period of time has worked or lived in cold and damp surroundings 
seems more likely to become infected. There appears to be an hereditary 
and personal predisposition to the disease, and having had it once pre- 
disposes to subsequent attacks. It attacks the strong and vigorous as often 
as it does the feeble and debilitated. It is most common in people who 
live in damp or ill ventilated rooms, basements, and subbasements (house 
infection) . 

Symptoms. — The onset may be gradual or sudden. If it is gradual, the 
patient will start with general malaise, headache, chilly sensations, slight 
fever, irritability, sleeplessness, lack of appetite, a coated tongue, and 
irregular pains about the joints. There may be slight soreness in the throat. 
If the onset is sudden, there are marked chills with a rapid rise of tempera- 
ture and severe pain in one or more joints. 

With the establishment of the disease the patient presents the appear- 
ance of a very sick person. The pain and tenderness are so marked that 
the patient lies perfectly motionless, with the joints slightly flexed, to relieve 
the tension within them. Usually one of the larger joints is first affected, 
as the knee, elbow, wrist, ankle, shoulder, or hip. The sternoclavicular, 
the intervertebral, the temporomaxillary, the symphysis pubis, and the 
sacroiliac articular surfaces are rarely affected. 

The joints are swollen, inflamed, painful, and tender, and the cases differ 
as to severity and tenderness, the number of joints involved, and the way 
in which one joint after another is involved. The general symptoms are 
those of a marked febrile condition. The skin, however, is usually moist and 
the patient may be bathed in acid perspiration. This is a striking feature 
of acute articular rheumatism, and thus it varies from other severe febrile 
conditions. The skin may, however, be hot and dry. The tongue is coated; 
nausea and vomiting are often present; the bowels are constipated; and 
the urine is highly acid, diminished in quantity, and loaded with urates. 
The intelligence is clear, but the patient suffers greatly and is usually very 
irritable, restless, and sleepless. The pulse is full and rapid. 

Couise. — With the modern treatment (salicylic acid preparations or com- 
pounds) , there is quick relief of the fever, pain in joints, and general symp- 
toms in the majority of cases. The duration of ordinary cases, without com- 
plications, seems to be about three weeks, but the disease may run its course 
in a few days or may last for months or be protracted by relapses. 

Complications. — 1. Endocarditis, coming on within the first ten days 
usually, is very common, particularly in children. The mitral valves are 



ACUTE ARTICULAR RHEUMATISM; RHEUMATIC FEVER 



549 



most often affected, and then the aortic. These lesions may leave the valves 
permanently damaged, or the patient may go on to complete cure. The 
endocarditis may become chronic. Endocarditis may exist alone as the 
only lesion of an attack of acute rheumatism. With its development during 
an acute polyarthritis the patients appear worse, the temperature rises, the 
heart's action becomes rapid, tumultuous, or irregular, and after one or 
two days a murmur is developed. 

2. Pericarditis, with the production of fibrin or fibrin and serum, usu- 
ally follows the joint lesion, but may precede it or be the only symptom of 
rheumatism. Pericarditis seems to be more common in men. Some 
patients recover completely, some have permanent pericardial adhesions, 
while a few die from the pericarditis itself. 

3. Myocarditis, very often present with pericarditis, is less frequent as a 
separate complication. The inflammations of the pia mater, pleura, or lung 
are rare and give their ordinary symptoms. The possibility of the occurrence 
of an inflammation of the ciliary body in the eye due to the poison of rheuma- 
tism must always be borne in mind. 

Rheumatism with hyperpyrexia, a most fatal form of rheumatism, 
although fortunately rare, begins mildly or severely. After a few days 
of the ordinary course, the temperature rises rapidly from 105° to 110° F., 
with a subsidence of the inflammation of the joints. If the sweating ceases, 
the tongue becomes brown and dry, the pulse rapid and feeble, and the 
breathing rapid. Soon the patient becomes restless and sleepless, the skin 
becomes hypersesthetic, and muscular twitchings develop, followed by general 
convulsions, delirium, coma, and death. Recovery is rare. Some authors 
call this cerebral rheumatism, and it is distinguished from rheumatic menin- 
gitis by the focal symptoms in the latter. 

Complicating Features. — Some of the rarer complicating features of 
rheumatic disease are erythema multiforme and nodosum, roseola, urticaria, 
peliosis, amygdalitis, thyreoiditis, chorea, and enteritis. Rarely do we find 
affections of the kidneys or cystitis or urethritis of purely rheumatic origin. 
Trigeminal neuralgia may be of rheumatic origin. 

The diagnosis is usually not difficult. 

Differential Points. — Osteoarthritis (arthritis deformans), a chronic 
condition, is most often seen in women exhausted by childbearing and lac- 
tation. It does not respond to the salicylates. 

Pyaemia from osteomyelitis of the long bones, involving a joint, or from 
osteomyelitis of the petrous portion of the temporal bone, with a preceding 
history of ear disease, must be distinguished. In the joint infection of 
pyaemia there is no shifting of the pain from joint to joint; the skin is not 
moist; the ulcerative endocarditis gives its peculiar temperature curve; 
the spleen is frequently the seat of infarct with its symptoms of tenderness 
and enlargement; and the kidneys may have infarcts, with albumin and 
blood in the urine. 

Gout usually attacks the metatarsophalangeal joints, and has gastric 
and other symptoms, with no involvement of the heart. 

Scurvy and rickets are usually diagnosticated by the history of improper 
food or malnutrition. 

Haemorrhage into a joint may occur in haemophilia. 



550 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



Monarticular rheumatism is usually characteristic of gonorrhceal infection. 
Look for gonococci in the urethra. If there is pain in the vertebrae, we may 
diagnosticate rheumatism by the medication test, viz. : with sodium salicylate. 

Multiple neuritis begins with severe pain in the extremities and along the 
course of the nerves. 

Hysterical joints exist in people who show other signs of hysteria. In 
such cases fever and swelling are absent. 

MANIFESTATIONS OF RHEUMATISM IN CHILDREN 

The joint affection is not so pronounced in children as in adults. We 
may have simply the mild growing pains, or there may be no joint pain. 
Occasionally the joint symptoms are quite severe. The other manifestations, 
however, are more frequently found in children — torticollis, erythema 
nodosum, purpura rheumatica, chorea, endocarditis, pericarditis, myo- 
carditis, or the formation of tendinous nodes. Rheumatic affections in 
children must be distinguished from syphilitic, scorbutic, and rhachitic in- 
flammation at the epiphyses, acute osteomyelitis, and septic arthritis. 

Endocarditis is the complication most frequently found in the case of 
children. 

Course and Termination. — Some patients recover completely and never 
have another attack; in some it runs its course, but leaves one joint inflamed; 
some have a long convalescence, become feeble and anaemic, and have stiff 
and tender joints for an indefinite time; pericarditis and endocarditis may 
result in serious permanent heart lesions. 

Death in acute rheumoiism is not frequent. It may be due to hyper- 
pyrexia, meningitis, pericarditis, endocarditis, pneumonia, pleurisy, etc. 

Treatment in Rheumatism. — The patient should be put to bed and not al- 
lowed to be up, no matter how mild the case is, until the acute symptoms 
have all disappeared. The following initial dose should be given to adults: 

R Podophyllin, gr. \; 

Calomel, ) 

~ • • , , aa, gr. x; 

Quinin. sulph., ) 

Pulv. aromatic, gr. iij. 

In a wafer. 

Constitutional Treatment. — Salicylic acid, gr. x to xx; sodium sali- 
cylate, gr. x to xx ; salol, gr. v to x; salophen, gr. v to x; oil of wintergreen, 
TTj, x to xx, in a capsule or in milk, or aspirin, gr. v to x, may be given 
every two hours until slight deafness and tinnitus aurium result, when the 
dose should be gradually reduced. The fever and pains often disappear 
under this treatment in from two to five days. The doses should not be 
too small or discontinued too soon, as recrudescences may appear. Care- 
ful watching is necessary to perceive the first toxic symptoms of the drug 
employed, gastric disturbances, delirium, cardiac weakness, albuminuria, 
and a tendency toward haemorrhages. Children receive the same treatment 
in smaller doses. 

The alkaline treatment was designed for fat subjects, for those suffer- 
ing from disturbances of digestion, or for gouty persons. Fuller's alkaline 



ARTHRITIS DEFORMANS 



551 



treatment is as follows: Potassium bicarbonate, 5j every three to four hours, 
adding 5j of lemon juice each time, and diluting with a considerable quan- 
tity of water. Continue it until the urine is alkaline, which usually takes 
from three to five days. Then give only gr. xxx of potassium bicarbonate 
in lemon juice and water as before, in combination with gr. ij to iij of quinine. 
Continue this for a long time. It is alleged that a patient is less liable to 
endocarditis with this treatment. 

The salicylates may be given in combination with the alkaline treat- 
ment or in combination with iodide of potassium and aconite or veratrum 
viride, particularly in cases with a very rapid action of the heart. 



M. S.: A teaspoonful every two hours for adults. One half a 
teaspoonful every two or three hours for children. 

Local treatment to the joints gives relief to the patient. The part 
may be encased in cotton and by means of splints rendered immobile. Oil 
of wintergreen, applied thickly and covered with rubber tissue, gives relief. 
Hot or cold applications, according to the choice of the patients, are used. 
Plaster of Paris splints are sometimes employed. 

The pain may be so severe as to require morphine or the coal tar anal- 
getics. The diet should be a fever diet. Enteroclysis should be done daily. 

Hyperpyrexia demands wet packs or cool baths. No time should be lost 
in reducing the temperature. 

The patient should be kept in bed for at least six weeks in severe cases, 
and the alkaline treatment should be continued for some weeks after the 
cessation of acute symptoms, or five drops of dilute hydrochloric acid may 
be given three times a day, in water. Anaemia demands iron. Undue 
exertion of the joints should be avoided, and the diet should gradually be 
made more liberal. A change of environment is often indicated. 

The hot air treatment, so beneficial in chronic joint pain, may also be 
employed in subacute articular rheumatism. Massage and vibration are 
also indicated after the acute symptoms are over. In protracted cases 
with persistent effusion, incision and drainage of a joint may be indicated. 
Adhesions may have to be broken up, if necessary under anaesthesia. 

Treatment of complications and sequelae is discussed under their respec- 
tive headings. 



Rheumatic arthritis, osteoarthritis, and chronic polyarthritis are used by 
different writers as synonyms. 

Definition. — A peculiar progressive inflammation and degeneration of 
the joints, accompanied with atrophy of some of the structures and hyper- 
trophy of others. Usually the parts involved are irrevocably damaged. 



Py Sodii salicyl., 

Potass, iodid., 

Tinct. veratr. virid., \ - - 
Tinct. aconit. radic, ) 

Aquse, 

Syrupi, 



5ij; 
3j; 



gtt. xv ; 



• . - oij; 
ad, OM- 



ARTHRITIS DEFORMANS 



30 



552 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



Arthritis deformans as seen in children presents no difference from the 
disease in adults, although it is rare. 

Pathology. — There is from the outset a slowly advancing chronic in- 
flammation, with degeneration of all the structures of the joint, a panar- 
thritis. It may begin in the ends of the bone or in the cartilage, with 
primary proliferation and afterward absorption. The changes in the bones 
are confined to the epiphyses. Later, denudation of the bone takes place 
at the point of maximum pressure. Friction gives the ends of the bone a 
smooth, lustrous, eburnated appearance. 

The proliferation of the cartilage from the inflammatory process causes 
it to undergo a fatty degeneration, becoming softened, eroded, and destroyed. 

The cavity of the joint may become 
so enlarged as to allow of a disloca- 
tion. The joint may become stiff- 
ened. The synovial membrane 
becomes thickened, adhesions may 
form, and there may be an increase 
in the amount of synovia, which 
becomes cloudy and thin, mixed 
with ground down particles of car- 
tilage. At times there is an ab- 
sence of synovial fluid. Thick 
plates of bone may form as a re- 
sult of an ossification of the cap- 
sule, flat or rounded or like stalac- 
tites. Parts of bone may become 
detached and remain isolated or 
unite into bony masses. Overlap- 
ping protuberances of proliferated 
cartilage or bone, form the nodules 
which are characteristic of one 
variety of the disease. A striking 
pathological change is the great 
proliferation of the joint villi. 
These become absorbed later on. 

The muscles entering into the 
joint mechanism show after a time 
decided atrophy, and the tendons 
become stretched and thinned. The interossei, the shoulder muscles, and 
the muscles of the thigh and calf of the leg may show atrophy. There 
may be dystrophy. Neuritis of the peripheral nerves has been found. 

The aetiology is obscure. In some instances the lesion occurs after 
rheumatic fever. Whether the original acute process is a true acute rheu- 
matism or whether it is an acute beginning of arthritis deformans does 
not seem to be settled. 

Varieties of the Disease. — Heberden's nodes, the general progressive 
form, the partial, or monarticular, form. 

Heberden's Nodes. — They may be regarded as the slightest and most 
chronic manifestations of rheumatoid arthritis. There may be a nodular 




Fig. 173. — Arthritis Deformans of Spine. 



ARTHRITIS DEFORMANS 



553 



involvement of the metacarpophalangeal joint of a thumb or occasionally 
of the dorsal aspect of the joints of the fingers. The disease becomes 
quiescent or extinct after a certain advance, but the marks remain. They 
are much more common in women than in men. 

The General Progressive, or Polyarticular, Form. — The hands 
are usually first affected, but the feet may be. It seems as if those joints 
which had been used most were the ones first involved. It is usual to have 
the joints involved one after another, advancing toward the trunk. The 
temporo-maxillary joint, rarely attacked in other arthritic conditions, is 
involved in this disease in about one fourth of the cases. Usually the 
disease is symmetrical. The articulations of the spine become affected 
later in the disease, the cervical region first, when it may remain, or the 
dorsal and lumbar regions may follow. This renders the back bent, twisted, 
shortened, and rigid. A complete ankylosis of the spinal column and hips, 
so that head, trunk, and thighs are firmly united, is occasionally seen. 

The partial, or monarticular, form is seen, where the knee, hip, and 
spinal column may be involved. It is apparently brought about by an 
injury and senility — senility not signifying so much old age as it does that 
morbid condition brought about by wear and tear, which is shown by 
changes in other parts of the body. If the hips are involved, the knees 
and lumbar and lower dorsal vertebrae may follow; if the shoulder is dis- 
eased, the elbows are likely to follow. When the hip alone is involved, it 
is the malum coxae senile of the older writers. 

There are many indefinite modes of onset, and no malady is more in- 
sidious in its invasion. The disease may be well advanced before a suspicion 
of its presence is aroused, which demonstrates the importance of early recog- 
nition. Actual joint disease begins with stiffness and pain, aggravated by 
motion or pressure. When the invasion resembles that of rheumatism, a 
swelling appears, and the joint becomes bulging and tender. The distal 
joints usually are the first affected. Sometimes only the distal phalangeal 
joints are attacked. The interphalangeal joints swell and give character- 
istic spindle-shaped joints. 

This is the way the disease invades many of the young adults, and it 
may not advance for months or years. The thumbs may escape, or only 
the carpometacarpal articulations become involved. The foot quickly 
shares in sympathy with the hand. The tarsal bones enlarge and become 
tender, synovial effusion takes place, the elasticity of the plantar arch is 
lost, and even slow walking becomes painful. The knee is likely to be more 
severely affected. A limitation of movement and a grating noise upon 
bending and rubbing the articular surfaces together are proofs of a destroyed 
mechanism. The crackling of periarticular adhesions is characteristic. 
Restrictions of motion by these adhesions may be as abrupt as if the bones 
themselves were at fault. 

Atrophy of muscles is uncertain in degree. It may be an early symp- 
tom of joint trouble, synchronous with or preceding the joint symptoms. 
It may be out of all proportion to the joint trouble. 

The skin about the joint may show dystrophy, becoming pink or glossy 
or translucent and pale. The flexor side of a finger may become thin and 
brittle, and the nutrition of the nail may suffer. 



554 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



Resultant Deformities. — In younger people, the fusiform appearance of 
the fingers is mostly due to synovial thickenings and thickening of the soft 
parts, while the Heberden nodes are osteophytic outgrowths. Bursal 
swellings are not uncommon in the neighborhood of joints, particularly on 
the dorsal aspect of the wrist, and enormous cysts have occasionally been 
met with in the thigh in connection with arthritis deformans. 

Spasm of the atrophied muscles may cause flexion of limbs at the knees 
or elbows and in extreme cases grotesque deformities of the hands and feet. 
The atrophy of the muscles about a joint makes the bony deformity more 
apparent. The bases of the first phalanges are directed obliquely to the 
ulnar side, so that the fingers assume more and more the appearance of 
subluxation. Often the phalangeal joints are so distorted that the second 
phalanx of the finger is markedly extended while the terminal phalanx is 
flexed. The palm of the hand is frequently hollowed out. 

The feet exhibit analogous deformities, but seldom to as great an extent 
as the hands do. Subluxation of the hip joint is not infrequent. The 
motion of the shoulder joint becomes more and more impaired as time 
advances. With the progress of the disease in the lower joints walking be- 
comes more and more painful, and later impossible without help or without 
crutches. 

General Course of the Disease. — It is an extremely chronic infirmity, 
lasting over ten or twenty years or longer; although there is continual 
advancement, there are sometimes periods of apparent arrest of the process 
which may extend over many months. There may be remissions and ex- 
acerbations affecting either the general or the local manifestations. Cardiac, 
kidney, glandular, and other constitutional symptoms are absent. 

Prognosis. — It is unfavorable. Recovery is extremely rare, and is pos- 
sible only in the early stages. For the encouragement of the patient it 
may be said that, under proper care and treatment, the disease often runs 
so gradual a course that the general condition remains at least bearable 
for a very long while, although there may be considerable local disturbance. 

Termination. — The disease is not directly dangerous to life. The eventual 
fatal termination ensues either from general debility or from some inter- 
current disease. 

Differential Diagnosis. — In the invasion the differential diagnosis between 
chronic rheumatism and arthritis deformans is very difficult. It is easier 
if we note in the beginning that in chronic rheumatism the inflammation 
attacks the connective tissue structures first, giving the characteristic 
crackling upon passive motion. This is never present in arthritis deformans. 
In the vertebral column it is still more difficult, although the final result is 
the same in both, namely, ankylosis. In arthritis deformans, during the 
early stages, knotty, bony clasps develop on the borders between two 
vertebrse, while in chronic rheumatism the ankylosis begins as a connec- 
tive tissue adhesion between the borders of the vertebra;. This later may 
become bony. 



ARTHRITIS DEFORMANS 



555 



DIFFERENTIAL DIAGNOSIS BETWEEN 
ARTHRITIS DEFORMANS AND CHRONIC RHEUMATISM 



More common in women. 

No history of acute rheumatism. 

In poorly nourished people. 

Pain mostly upon motion. 

Disease progressive. 

Small joints first attacked. 

Temporomaxillary joint often at- 
tacked. 

Deformity symmetrical. 

Weather seems to have no effect 
upon it. 

Increased diet improves the patient. 



Seen about equally in both sexes. 
History of acute rheumatism. 
Frequent in well nourished people. 
Pain more or less constant. 
Periodical attacks. 
Large joints first attacked. 
Seldom if ever attacked. 

Not symmetrical. 

Disease is worse in cold damp 
weather. 

Increased diet apparently has no 
effect. 



For the differential diagnosis between arthritis deformans and gout, see 
the chapter on Gout. 

The progressive joint lesions of organic nervous lesions present associ- 
ated nervous phenomena which enable us to distinguish between it and 
arthritis deformans. The same may be said of joint syphilis and joint 
tuberculosis. Gonorrheal arthritis presents a different picture entirely. 

Treatment. — That the treatment of arthritis deformans may have any 
chance of success, the following requirements must be complied with: 
1. It should be begun as soon as possible after the appearance of the 
earliest signs of the disease. 2. It must be such as to increase the pa- 
tient's strength, and all opposite measures must be avoided. 3. To be 
effectual, it must be carried on for months or even for a year or two with 
short intermissions. 

Prophylaxis. — Hygienic living in the strongest sense of the term is 
the best preventive of this disease; sufficient and proper nutrition, regular 
sleep, exercise, bathing, and amusement. If one's occupation is tiring to 
one's hands and fingers by reason of forced and unnatural positions, there 
must be a corresponding change and relaxation. The dwelling house should 
be dry and warm, but not of a nature to lessen one's power of resistance. 
After the onset, the strictest rules of hygiene must be followed. The most 
wholesome and abundantly nutritious diet must be allowed ; regular exercise, 
sleep, and amusement must be insisted upon. 

Climate. — A dry and temperate climate seems most favorable. 

Baths are of undeniable value, although they must not be overesti- 
mated. Simple warm baths or salt baths (two to ten pounds of salt in each 
bath) may be used in any home. 

The following resorts for bathing and drinking are considered best for 
cases of arthritis deformans: Teplitz, Wildbad, Ragatz, and Baden in 
Switzerland (warm baths) ; Wiesbaden (warm chloride of sodium baths) ; 
Oeynhausen and Nauheim (acidulated baths) ; and Elster, Marienbad, 
Franzenbad, and Schmiedeberg (mud baths). 

Steam baths may be employed cautiously in the early stages where the 



556 



OSSEOUS. MUSCULAR, AND ARTICULAR SYSTEM 



general health is still good. In this country the baths at Sharon and Rich- 
field in New York State, the Sulphur Springs of Virginia, and the Hot Springs 
of Arkansas are recommended. Hot sand baths have been known to do 
good, not only from the temperature, but from the uniform and continuous 
pressure. They are given elaborately at Kostritz and Blasewitz. 

Hot air treatment, such as is given in hospitals and may be given in the 
home of the patient, is as efficacious as any form of bath. 

Enteroclysis with hot water (110°) should be practised daily. 

Drugs. — We always administer drugs internally with the hope of modify- 
ing the disease, but the chief reliance is placed upon local treatment. 
Iodine, the iodides, and arsenic stand first. Iodine may be given in the 
form of the tincture, a few drops in mucilage several times a day or, better, 
in combination with potassium. Arsenic has given benefit. It may be 
administered in the form of pills of arsenious acid, gr. - g L- to T ^ two or 
three times a day for several months. Salicylic acid and antipyrine may be 
used in acute exacerbations to alleviate pain. Colchicum seldom does any- 
good. Iron and quinine may be indicated. Hyoscyamus has been found of 
value in the attacks of acute paroxysmal pain. Ichthyol might be tried 
for its disinfecting qualities in the intestinal tract in two drop doses three 
times a day. Diphtheria antitoxine and ductless gland preparations have 
been used in arthritis deformans. 

Local Treatment. — By means of local treatment and baths we appar- 
ently accomplish more than by internal medication. Massage comes first, 
although the resulting benefit is likely to be evanescent. To aid in the 
absorption of inflammatory products, to loosen up joints, to invigorate the 
muscles, and improve the general health, massage is temporarily of great 
benefit. It must be continued for a long time, but if too long, it seems to 
do harm rather than good. Continued dry massage seems to do more good 
than a short course of douche massage. Vibratory massage is excellent. 

Superheated dry air probably offers better chances for improvement than 
any form of medication. Liniments, ointments, and other local remedies 
seem to be of benefit only from the accompanying massage. The deformi- 
ties may require surgical interference. 

CHRONIC RHEUMATIC ARTHRITIS; CHRONIC RHEUMATISM 

This is a result of repeated acute attacks, or it may gradually begin as 
a chronic inflammation in persons constantly exposed to cold and dampness 
or suffering privation. 

The treatment consists in protection from moisture and cold; in im- 
proving the general health and in intestinal irrigation. Massage, dry heat, 
vibratory stimulation, and electricity in combination with tonics are bene- 
ficial. Contractures and adhesions may be benefited by surgical measures. 

Syphilitic Arthritis 

In acquired and congenital syphilis, there may be arthritis. The pain 
is not severe, the systemic symptoms are not marked, and the enlargement 
of the joints is not uniform, but shows doughy areas. The skin is not red 
nor does it show any signs of inflammation. The treatment is antisyphilitic. 



TUBERCULOSIS OF THE JOINTS 



557 



TUBERCULOSIS OF THE JOINTS 

The exciting cause may usually be traced to some injury, such as a sprain, 
blow, twist, or exposure, but sometimes there seems to be no exciting cause. 
In adults we find tuberculosis of the synovial membranes more frequently, 
while in children it attacks usually the bones. There may be an active 
hyperemia, with swelling, or the process may develop more slowly, with 
congestion, oedema, and the abundant development of granulation tissue. 
This latter may cause a baggy condition of the whole synovial sac, with 
little or no effusion into the joint. Hence, in this form, great deformities 




Fig. 174. — Hip Disease Showing Flexion Deformity. 



may exist. Effusion is marked in other cases, with much less development 
of granulation tissue. 

Symptoms. — The swelling at a joint gradually becomes spindle-shaped. 
The skin becomes white and thick (white swelling) and the presence of 
fluid, serum or pus, will give fluctuation. Pain is usually slight, there 
being more when the disease begins in the bone. It can be elicited by pres- 
sure or by certain motions. There may be a slight rise of temperature and 
the joint may feel warm to the touch. Deformity from swelling, from soften- 
ing and degeneration of the ligaments, from muscle spasm and atrophy, 
and from the tendency to assume certain attitudes as a means to relieve 
pain, is present. 

The muscular spasm, a reflex action producing rigidity of the joint, is 
one of the first and most important symptoms. The function of the joint 
gradually becomes affected. With fatty and caseous degeneration and the 
accumulation of tuberculous fluid, perforation, with the formation of sinuses, 
may take place. Systemic infection is possible at this time. 

Diagnosis. — There is often the hereditary taint in these cases. Tuber- 
culous joints most often occur in the quite young and quite old. The process 
may be confounded with syphilis in the young, but there will usually be 
Other evidences of syphilis. It is very difficult sometimes to determine 



558 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



whether the disease was primarily in the bone or in the synovial membrane. 
If it is primary in the bone, and not far advanced, the loss of function, 
swelling, and muscular resistance may be so little marked as to make the 
diagnosis difficult. The circumscribed point of tenderness, corresponding 
to the original focus, is an aid in diagnosis. By means of an x ray print we 
can demonstrate a tuberculous focus. 

Prognosis. — The extent of the local disease and the general health of 
the patient largely influence the prognosis. Healing of a joint may occur 
with slight or complete ankylosis. There may be abscess formation with 
necrosis of the ends of the bones. The patient may die from general 
tuberculosis. Some cases run a course for years and finally end in recovery, 
with more or less ankylosis. If we recognize the first of the three stages, 
muscular spasm, we may be able to bring about healing with very slight 
ankylosis. The two other stages, effusion or granulation and abscess, 
mean more destruction. 

Treatment. — Spontaneous cure is rare. Complete rest is of the greatest 
importance, combined with fixation and general climatic, hygienic, and 
tonic treatment. Bier's treatment consists in creating congestion of a joint 
by applying an elastic bandage above. For example, if we have to deal 
with a tuberculous knee joint, we should put on a spiral circular rubber 
bandage, having the rubber on the stretch, above the knee, with a layer of 
flannel adjusted smoothly underneath. The pressure must be moderate 
and the treatment must be continued for months, the bandage being left 
on for hours at a time. In many cases surgical treatment will be necessary. 

LOOSE BODIES IN JOINTS 

These are composed of bone, fibrocartilage, or fibrous material, and are 
met with occasionally, most often in the knee joint. They may be free in 
the joint or attached by a pedicle. They originate from portions of bone or 
cartilage detached by injury, from the synovial fringes or from detached 
osteophytes, and vary in size usually from that of a pea to that of a lima bean. 
Occasionally one may be even larger. Blood clot may organize into fibrous 
bodies. An x ray print will demonstrate loose bodies in joints. 

Symptoms. — There is usually, first, a sudden severe pain in the joint 
with apparent inability to move it in any direction. Nausea and even 
vomiting may be present. Soon signs of fluid may develop. After a few 
days usually all symptoms disappear, due to a change of position of the 
foreign body. Sooner or later, perhaps months later, the body may again 
be wedged between the articular surfaces and cause the severe pain. Some- 
times patients may feel the foreign body slipping around in the joint, and 
sometimes flexion and extension will dislodge it. Sooner or later a loose- 
ness of the joint results from stretching and synovitis develops. 

The treatment is palliative and operative. A close fitting bandage or 
knee cap sometimes suffices to keep the body from slipping between the 
articular surfaces. 



NEUROPATHIC ARTHRITIS 



559 



DISPLACEMENT OF THE SEMILUNAR CARTILAGES 

This accident may happen to these cartilages of the knee joint by injury 
or by the weight of very heavy people. The displacement may be slight 
or the cartilage may be set entirely free, enabling it to become wedged 
between the tibia and femur, firmly locking the joint. 

Symptoms. — There is a sudden pain, the knee becomes partially fixed, 
and the joint is locked. Nausea and vomiting may result from the severe 
pain. Swelling and effusion may appear. All the symptoms recede with 
reposition of the cartilage. After such a stretching, we observe an abnormal 
lateral mobility of the joint, and the ligamentum patellae is often elongated. 
When the knee is slightly flexed, there is a slight twisting motion, and this 
is largely effective in producing the dislocation. A semilunar cartilage once 
displaced is therefore likely to slip again. 

Treatment. — Flexion and extension, with slight rotation, will usually 
suffice to replace it. An anaesthetic may be required. If an apparatus is 
constructed and worn to prevent complete extension, lateral motion, and 
separation of the inner condyles, such as the Shaffer apparatus, a recurrence 
can usually be avoided. Operative measures may be necessary. 

NEOPLASMS OF JOINTS 

Primary new growths in joints are rare, but we see metastases rather 
often. Sarcomata and chondromata are the most frequent and require 
surgical treatment. 

NEUROSES OF JOINTS 

Hysteria manifests itself in joints in the form of painful conditions or 
contractures. 

Neuralgic conditions, due to neurasthenia, malaria, disease of the brain 
or spinal cord, or injury or pressure upon nerves supplying a joint, are often 
met with. There is no apparent pathological change, and function may 
be perfect, although we see such pains in a joint after recovery from an 
injury, such as sprain or contusion. The pain is of a burning or lancinating 
character, and is most apparent when the patient is fatigued. 

The treatment is with massage, hot dry air, vibratory stimulation, etc., 
combined with general tonic treatment. The actual cautery is of benefit 
in hysteria. 

NEUROPATHIC ARTHRITIS 

Charcot's joint, or neuropathic arthritis, affects a large joint, particularly 
the knee. It begins acutely with effusion, but without pain or rise of tem- 
perature. Later there is a degeneration of the cartilages and surrounding 
structures, often with great enlargement of the ends of the bones, a change 
similar to that in arthritis deformans. There is a grating of the joint surface, 
with much mobility, often leading to partial or complete dislocation. 
Muscular atrophy is rapid, and degeneration of the bone in this region may 
lead to fracture from trivial injury. 

Treatment. — As this is a symptom of locomotor ataxia, the only benefit 
we may hope to give is from treatment of that disease. The joint should 



560 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



be protected to prevent dislocation and fracture. Spontaneous dislocation 
of joints is occasionally observed in flabby, anaemic individuals without the 
neuropathic element. 

BURSITIS 

The bursa? connected with tendons or joints or situated elsewhere are 
the seat of injuries or inflammations from continued friction or pressure. 

Acute bursitis presents tenderness, pain, redness, and distention of the 
bursa. Should suppuration arise, the surrounding tissues may be involved, 
and as the deeper bursa? may connect with or be closely associated with a 




Fig. 175. — Charcot Knee Joint (Tabes Dorsalis). 



joint, the condition may become quite serious. The location of the swelling 
and its globular shape suffice for the diagnosis. 

The treatment consists in rest, elevation, pressure, or cold, and pos- 
sibly a splint. If there is suppuration, surgical treatment is required. 

Chronic bursitis, from a non-suppurative acute bursitis, or developing 
slowly from long continued irritation or pressure or from tuberculosis, exists 
with no, or very slight, pain. The sac is distended with fluid, and may 
become so thickened as to form a solid tumor. Housemaid's knee, or a 
chronic prepatellar bursitis, from frequent and long continued kneeling; 
miner's elbow, an inflammation of the olecranon bursa; and bunion are the 
forms most frequently seen. 

Differential Diagnosis. — Gummata of the prepatellar bursa? are 
common, and this condition should be suspected. Ganglion is probably a 
cyst arising from the sheath of a tendon or from the tendon itself and not 
connected with bursa; or synovial membranes (see Diseases of Tendon). 
The location should determine a bursa. 

The treatment is surgical. 



CHAPTER XXII 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM — Continued 

DISEASES OF MUSCLES, TENDONS AND FASCIyE 

Synopsis: Muscles: Remarks on Injuries, Degeneration, etc. — Myalgia (Traumatic and 
Rheumatic). — Wry Neck. — Lumbago. — Backache. — Cramps in Legs. — Myositis. — 
Trichinosis of Muscles. — Myotonia. — Myoclonia. — Muscular Dystrophies. — Tendons: 
Injuries. — Lengthening and Transplantation of Tendons. — Suppurative Tenosynovitis, 
Tuberculous Tenosynovitis. — Tumors of Tendons. — Fasciaj. — Injury and Contracture. 

THE MUSCLES 

Injuries. — Muscles are subject to incised, lacerated, and contused 
wounds. The latter may be subcutaneous. The injury may be direct 
from without or due to sudden forcible contraction. In every instance 
there is more or less disturbance of function. 

Rupture, complete or partial, may take place in a muscle and may be 
associated with great pain and loss of function, and, in case a large muscle 
is involved, with complete rupture, a deformity presents itself at the site 
of rupture, due to contraction of the two ends, with a furrow between them. 
A form of wry neck, a condition known as congenital tumor of the sternocleido- 
mastoid, may be the result of a partial rupture of this muscle during a difficult 
labor (see Paediatrics). 

Strains and Sprains. — Simple stretching or laceration of a few fibres of a 
muscle is of frequent occurrence. Some loss of function may result. Repair 
takes place with the formation of fibrous tissue. 

Treatment. — Incised and lacerated wounds and complete ruptures de- 
mand surgical treatment. Strains and sprains call for rest, suitable splints, 
strapping or bandaging, and early or subsequent massage and vibration 
treatment. 

Degeneration of Muscle. — A fatty degeneration largely confined to the 
connective tissue may result from long continued inflammation or disuse. 

Intrinsic fatty degeneration of the muscle fibres themselves, a more 
complete form of degeneration, is occasionally seen. 

Granular, waxy, and calcareous degeneration are observed from time to 
time. In rhachitis the muscles are flabby from imperfect nutrition, and 
sometimes atrophied from disuse. 

The treatment consists in passive motion, vibration, massage and 
electricity, and proper diet. 

Ossification of a portion of the belly of a muscle at its insertion, as a 
result of long continued irritation, is sometimes seen. The "rider's bone," 

561 



562 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



a calcareous deposit in an adductor muscle of the thigh, occurs in those who 
ride horseback constantly. 

Atrophy of muscles from severe injury, following disease of a joint or of 
the spine, or from contusion, is often seen. It may be associated with 
fatty degeneration. It is a prominent symptom in progressive muscular 
atrophy. 

Hypertrophy is either an actual increase in the size and number of muscle 
fibres, seen as a result of excessive use, or it is due to increase in the con- 
nective tissue, lymphatics, or blood vessels of the muscle. 

Contracture of muscle, a permanent shortening, may be caused by in- 
flammation, loss of substance, disease of joints, paralysis of the opposing 
muscles, cicatricial contraction, and disease of the central nervous system. 
Hysteria and chorea may cause a temporary shortening by contracture. 

The treatment is described in the chapter on Orthopaedics. 

Tumors of Muscle. — These may be benign or malignant. Among the 
former we find syphilitic, fibrous, cystic, vascular, cartilaginous, and osseous 
growths. Cysticercus cysts are rare. Malignant tumors, carcinomata and 
sarcomata, of muscle are not uncommon. The treatment depends upon the 
nature of the growth. Surgical interference is usually necessary. 

Myalgia; Pseudorheumatism. — Until our pathology of this subject is 
rendered clear, these terms may be used interchangeably. They express 
a painful condition of a voluntary muscle, which may be due to trauma, 
a slight strain, a twist, or a laceration. In such cases there is probably 
a slight inflammation of the muscular tissue. It may also be caused by 
infectious diseases, such as syphilis or malarial disease, or it may be due to 
intoxication by alcohol, mercury, or lead. 

Muscular rheumatism, or rheumatic myalgia, is probably caused by the 
same infective agent which produces acute articular rheumatism. It 
apparently arises from the same predisposing causes as the arthritic type. 

In some cases fibrous nodules are found in the affected muscles. No 
muscle is exempt, but the ones most frequently involved are the quadratus 
lumborum (lumbago), the sternocleidomastoid (acute wry neck), and the 
intercostals (pleurodynia). Appendicitis and cholecystitis are sometimes 
mistaken for rheumatism of the abdominal muscles, and vice versa. 

The prominent symptom is pain in the muscle affected, with or 
without a rise of temperature. Each contraction of the muscle is likely to 
be agonizing. Complications, such as endocarditis and the cutaneous 
lesions: petechia, erythemata, urticaria, and peliosis, have been observed, 
but are not ordinarily seen. 

The treatment is antirheumatic in the acute stage, with rest, heat or 
cold, or strapping. Massage or vibratory stimulation is indicated, and it is 
especially efficacious when nodules are found. 

Lumbago. — A common and painful affection of the muscles of the loins 
of traumatic or rheumatic origin, with sudden onset lasting from a few hours 
to several days. 

Treatment. — A hypodermic injection of morphine (gr. \ to \) over 
the seat of pain will give prompt relief. This is to be followed by massage 
and vibratory massage. Rest of the affected muscles will generally prolong 
the trouble. In chronic cases hydrotherapy and massage are indicated. 



MUSCULAR RHEUMATISM, MYALGIA, MYOSITIS 



563 



Torticollis, besides being rheumatic or malarial in origin, may be due to 
an injury during childbirth, affecting either the nerves or muscles. It may 
also follow a lateral curvature of the spine as a compensatory distortion. 
A new growth in the sternomastoid, a gumma, or a sarcoma may cause 
torticollis. Abscess of the neck, enlarged cervical glands, or hysteria may 
give rise to this condition. The trapezius may be involved with the sterno- 
mastoid, and occasionally the splenius, scaleni, and platysma are involved. 

Treatment. — (1) Medicinal, (2) mechanical, (3) operative, all of which 
is described in the chapter on Orthopaedics. Where it appears as an acute 
condition, rheumatic, or from some other infection, commonly described as a 
stiff neck, a forcible bending in the opposite direction, a painful procedure, 
will often give immediate and permanent relief. When the underlying 
cause is unknown, we may begin treatment by giving first a laxative and 
subsequently quinine or salicylate of sodium, to be followed by manual or 
vibratory massage. 

Backache is not usually of muscular origin, but may be due to many 
causes, such as arthritis deformans and Pott's disease, and injuries to and 
strains and sprains of the dorsal ligaments. From lateral curvature there 
also occurs a straining of ligaments. Faulty position in standing and walk- 
ing is a frequent cause. In consequence of weakness and fatigue, the weight 
of the body is allowed to rest upon the ligaments of the vertebras instead of 
the spinal muscles. We see, as characteristic of this, people with round 
shoulders, head thrust forward, abdomen protruding, and a shiftless, wad- 
dling, and ambling gait. Flat foot, pronated foot, a condition in which 
there is a tendency of a normally arched foot to bend inward, and con- 
tracted foot, when for some reason the muscles of the calf are contracted, 
are mentioned as being somewhat common causes, also diseases and atony 
of the muscles, and neurasthenia and hysteria. In the pelvis, there may 
be pressure upon the sacral nerves from any cause, frequently from con- 
stipation. Malposition of the uterus, most often retroflexion, by pulling 
upon the posterior ligaments, is a frequent cause of backache in women. 
Affections of the cervix uteri, principally new growths, are mentioned as 
causes. Backache is a usual symptom of infective fevers and intestinal in- 
toxication. 

Treatment. — Injuries and sprains of ligaments demand rest and fixa- 
tion and possibly orthopaedic attention, as do also tuberculous affections 
and deformities of the foot. Faulty position calls for tonic treatment, 
exercise, and gymnastics. Backache in women is usually cured by wearing 
an abdominal supporter and taking a laxative pill at bedtime. 

Cramps in the legs are due to many causes. They are very troublesome 
in cholera, gout, and chronic Bright's disease. They are observed frequently 
in conditions of varicose veins, flat foot, and contracted foot. The treat- 
ment must be directed to the underlying cause. 

Myositis as a primary disease is very rare and of unknown cause. It is 
characterized by swelling, tenderness, and stiffness of the muscles, associ- 
ated with pain on motion. There may or may not be oedema of the sub- 
cutaneous tissue. Frequently there are resemblances to an acute infection. 
The course is from several months to several years, and no curative treat- 
ment is known. The affection may become of a serious or fatal nature by 



564 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



involving the muscles of respiration and deglutition. In that it simulates 
trichinosis, we can distinguish it only by microscopical examination of the 
muscle fibres. 

Acute purulent myositis, usually associated with pyaemia, occasionally 
with other septic conditions, resembles purulent inflammations in other 
parts of the body. It has been looked upon in a few cases as primarily an 
acute infection. 

Myositis ossificans is a rare progressive disease in which the muscles 
become bony. It may be limited to certain muscles or be general. 

Myositis Due to Trichinosis. — A localized inflammatory condition of a 
muscle caused by the Trichina spiralis becoming encysted in the substance 
of the muscle. The parasite's habitat is the hog. When its meat is eaten 

raw or imperfectly cooked, the parasites develop 
in the intestinal tract and migrate to the mus- 
cle, which they reach on about the sixth day. 
Within the capsule which they form for them- 
selves in the muscle they may live for years. 

Symptoms. — The first to appear are the 
gastrointestinal symptoms, which manifest them- 
selves one or two days after eating the diseased 
pork. There are nausea, vomiting, abdominal 
pain, and a serous diarrhoea. The worms, re- 
sembling glistening white threads, may be found 
in the stools. In some cases typhoid fever or 
cholera may be suspected in the presence of high 
fever. Very severe cases may terminate fatally 
in the early stage, probably from intense intoxi- 

Fig. 176. — Trichina Spiralis cation. 

Encysted in Muscle. Muscular symptoms develop in from one to 

two weeks. The muscle becomes swollen, ten- 
der, and exceedingly painful. The skin over the muscle may be cedema- 
tous. If the respiratory muscles are involved, dyspnoea occurs and there 
is a liability to the development of bronchitis and bronchopneumonia. 
One of the most characteristic early symptoms is (edema of the eyelids, 
usually appearing by the seventh day. Irregular fever, profuse sweating, 
albuminuria, and loss of reflexes are usually present. 

The diagnosis is made from the history of the patient's having eaten 
raw or improperly cooked pork, from finding a number of persons suffering at 
the same time, and by examining the stools, or later in the disease an excised 
piece of muscle. Eosinophilia has been found in the majority of cases. 

The course is from two to eight weeks, and recovery is slow and 
tedious. 

The prognosis is grave, as about 30 per cent of the patients die, 
chiefly from pulmonary complications. 

The treatment is prophylactic, by avoiding raw or poorly cooked pork. 
In the gastrointestinal stage, give a brisk purgative. Calomel, gr. x, or 
glycerine, in 5ss doses, every hour, and thymol, in gr. v doses, in a capsule 
have been recommended. When the parasite has encapsulated itself in 
the muscle, the treatment can only be symptomatic. 




THE MUSCULAR DYSTROPHIES 



565 



Myotonia (Thomsen's disease) is an affection characterized by a tonic 
cramp of muscles when the patient attempts to bring them into use. Usually 
the disease is hereditary, but there are acquired forms which are very similar. 
The cause is unknown, but the disease is seen in family groups and very 
rarely in isolated cases. It is more common in Germany and Scandinavia 
than in England and this country. It is not known whether there is a 
defect in the innervation of the muscle or whether it is a primary disease 
of the muscles. 

Symptoms. — There are painless tonic spasms, which occur whenever 
the patient begins to use the muscles. Voluntary relaxation and contrac- 
tion are slow, and there seems to be a stiffness of the muscles. After re- 
peated use, the muscles become limber. Cold or nervousness increases the 
spasms. The electrical and mechanical reaction of the muscles is increased. 
They may undergo hypertrophy. The general health of the patient is 
below par. Mental deficiency is present in many cases. The disease is 
incurable, but apparently does not shorten life to any extent. 

Treatment is futile, although Thomsen, who suffered from the disease 
himself, thought that active muscular exercise was of some help to him. 

Myoclonia, or paramyoclonus multiplex, is a rare affection, occurring 
chiefly in adult males, characterized by clonic muscular contractions, 
principally in the muscles of the extremities. These contractions occur 
constantly or in spasms, and may follow fright, injury, or emotion. The 
spasms are usually bilateral, and occur at the rate of from 50 to 150 a minute. 
There are no sensory or psychical associated symptoms. At times the 
spasms are so pronounced that the body is tossed about so as to make it 
difficult for the patient to remain in bed. Between the attacks there is 
likely to be a general tremor. In sleep the spasms do not take place. The 
bodily strength is generally impaired. It is believed to be a pathological 
manifestation of degeneracy. 

Treatment. — In addition to tonics and hydrotherapy, measures must 
be resorted to to quiet the spasms. Chloral and hyoscine are indicated to 
accomplish this purpose. 

The Muscular Dystrophies 

Progressive muscular dystrophy is a wasting of the muscles, frequently 
with a preceding hypertrophy, which is due to changes in the muscles them- 
selves. 

jEtiology. — We do not know the cause, but we have noticed that it has 
a tendency to develop in families, and that males are oftener affected than 
females. It usually begins before puberty, but occasionally develops as late 
as at twenty-five or even thirty years. 

Symptoms. — The first signs of the disease are a certain clumsiness and 
awkwardness of motion developing in a child who previously seemed normal. 
We find certain muscles or groups of muscles enlarged, those of the calves 
most often. But also those of the extensors of the legs, the glutsei, the 
lumbar muscles, the deltoid, the triceps, and the infraspinatus are enlarged 
sometimes. Those of the neck, face, and forearm rarely suffer. There is a 
wasting of other muscles, particularly the lower portion of the pectorals 
and the latissimus dorsi. Loose shoulders are an early characteristic. 



566 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



The attitude in standing is characteristic — legs far apart, shoulders 
thrown back, abdomen protruded, spine greatly curved. The method of 
getting up from the floor is pathognomonic. The hands are placed upon the 
knees, and the child "climbs up its legs." The gait is awkward — a sort of 
waddle. There is a striking contrast between the feeble appearance of 
the child and its powerful looking muscles. As the disease progresses the 
wasting advances. Later all signs of hypertrophy disappear and deformities 
may develop. There are no sensory symptoms. The knee jerk is normal. 
The reaction of degeneration is not obtained. 

Varieties. — According to the age at which the disease develops, we ob- 
serve the following varieties: 

I. Those beginning in childhood. 

1. Hypertrophic form: 

a. With pseudohypertrophy, lipomatosis. 

b. With real hypertrophy. 

2. Atrophic form: 

a. Infantile form of Landouzy and Duchenne, in which the 

muscles of the face and shoulder girdle are involved. 

b. In which the face is not involved. 

II. Cases occurring in youths and adults (juvenile form of Erb). 

Pathology. — The disease process is confined to the muscles, the spinal 
cord and the peripheral nerves being normal. The muscle fibres hyper- 
trophy; the muscles increase; the connective tissue increases; fat is de- 
posited about the muscles. Later there is atrophy, and finally the muscles 
involved resemble fat tissue. 

Diagnosis. — In cerebral atrophy the loss of power comes first. In cen- 
tral progressive muscular atrophy, usually occurring late in life, the process 
begins in the small muscles of the hand (where the dystrophies never start) . 
Reaction of degeneration and fibrillary twitchings are present; in most 
cases the reflexes are increased and there is a spastic condition of the legs. 
There is no hereditary tendency. Death is usually due to some intercurrent 
malady. 

Treatment does not seem to influence the disease. Exercise seems best. 
(See also Paediatrics.) 

THE TENDONS 

Rupture. — Sudden violent and unusual muscular effort may completely 
or partially rupture a tendon. The ones most liable to rupture are those of 
the quadriceps extensor femoris, the long head of the biceps, the ligamentum 
patellar the triceps, and the tendo Achillis. Sometimes instead of a rupture 
there is a tearing away of the tendon at its insertion, including the perios- 
teum, the fibrous capsule, and even a portion of the bone. 

Symptoms. — The patient has the sensation of something giving away 
with a sharp pain, followed by loss of function. There may be perceptible 
through the skin a decided furrow, corresponding to the gap between the 
torn ends of the tendon. 

Treatment. — If there is a gap between the ends of the tendon, it is 
hardly likely that repair will take place without operation. If we think the 



THE TENDONS 



567 



rupture is not complete, we may immobilize the limb in the best position 
to relax the tendon, and approximate the torn parts. Usually operative 
procedures are necessary. 

Wounds of tendons are important on account of the likelihood of intro- 
ducing infection. The whole tendon may be divided. The treatment is 
surgical. 

Lengthening and transplantation of tendons have been successfully done. 
In case of paralysis of a certain group of muscles, from anterior poliomye- 
litis, a tendon from one muscle has been attached and sutured to the peri- 
osteum at a point where it could help to do the work of a paralyzed muscle. 

Dislocation of a tendon may result from extreme violence, particularly 
that of the long head of the biceps from the bicipital groove, or the peroneus 
brevis may be displaced forward, or the tibialis posticus displaced from 
behind the internal malleolus. If, after reposition and rest, it recurs, 
operative measures are necessary. 

Tenosynovitis, or thecitis, or inflammation of the synovial sheaths of 
tendons, may be an acute or a chronic condition. 

Acute non- suppurative tenosynovitis usually results from strains, sprains, 
or excessive unaccustomed use, and is found in persons suffering from chronic 
malarial poisoning or chronic circulatory disturbances. The tendons of the 
wrist and those just above the ankle are most often affected. 

The symptoms are pain, particularly on moving the extremity in which 
the tendon lies, partial loss of function, and a peculiar dry crepitus upon 
motion. 

Treatment. — Rest on a splint and counterirritation, vibratory mas- 
sage, and hot air treatment. 

Suppurative tenosynovitis results from an infection of a tendon sheath 
due to a penetrating wound or one which may be so insignificant as not to 
be noticed, or from the blood. This form frequently arises from the ex- 
tension of a felon into a tendon sheath by direct continuity, and usually 
forms part of a more or less extensive phlegmon. For symptoms, there 
are redness, swelling, throbbing pain, and marked constitutional disturbance. 
The flexor tendons of the hands and feet are most frequently involved, and 
from the anatomical structures there is a serious tendency for the process 
to spread. 

The treatment must be surgical, and the sooner free drainage is 
established the better. 

Chronic tenosynovitis, or tuberculous tenosynovitis, is characterized by 
swelling and induration in and around a tendon sheath, due to tuberculous 
granulation tissue. There may be irregular swellings, showing fluctuation, 
which contain a fluid with little whitish bodies resembling rice grains and 
called "rice bodies." Sometimes we may find the tubercle bacilli in the 
fluid. The places of predilection for tuberculous tenosynovitis are the wrist, 
the ankle, and the knee. It may follow a slight injury or infection from a 
tuberculous joint. The process advances slowly and rarely undergoes spon- 
taneous cure. There is a tendency for it to become secondarily infectious, 
and for suppuration to take place. Even with considerable swelling, there 
is very little pain, and only a very slight impairment of function. 

The treatment is surgical. 
37 



568 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



Ganglia are small cysts which appear along the course of tendons, prin- 
cipally those of the radial side of the wrist and especially on its dorsal aspect. 
They are also found in the palm of the hand, on the flexor aspect of the 
fingers, on the dorsal aspect of the foot, and about the insertions of the 
hamstring muscles. The contents are colloid or jellylike. There is con- 
troversy in regard to their origin, but it is supposed that they arise from a 
degeneration of the tendon itself or a growth of the sheath, rather than from 
a hernia of the sheath. 

The treatment consists in breaking the cyst wall by means of a sudden 
sharp blow with a book or other hard object, scattering the contents, which 
are absorbed. Sometimes they recur, when excision is indicated. 

Compound ganglion is another name for a tuberculous tenosynovitis. 

Tumors of tendons, of primary origin or from extension from other parts, 
may be benign or malignant. Syphilitic growths may originate here. A 
small fibroma developing here may produce a very marked disability. 

Ossification of tendons sometimes takes place at their insertions. It 
may be the result of constant irritation from a rheumatoid arthritis or from 
a callus following an injury to a contiguous bone. 

The treatment, if any is demanded, is surgical. 

THE FASCIA 

The fascia? in different parts of the body may be injured or diseased. 
As the blood supply to this tissue is poor, gangrene may occur when disease 



sets in. Wounds and solution of continuity of fasciae permit of hernia of 
muscle, and also open up regions where serious destruction from infection 
may occur. 

The treatment is surgical. 

Contractures of fasciae, as a result of inflammation, traumatism, gout, 
or rheumatism, give rise to marked deformities. The fascia lata, the 
popliteal fascios, and the palmar fasciae (Dupuytren's contracture) are most 
frequently involved. 

The treatment is surgical. 




Fig. 177. — Contracture of Palmar Fascia. 



CHAPTER XXITI 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM — Continued 

ORTHOPEDIC MEMORANDA (& P S6s, straight; ™8.'w, a child) 
By C. H. Jaeger, M. D. 

L'orthopcdie, ou Vart de prevenir et de corriger dans les enfants les diformitis du 
corps. — Andry, Paris, 17&1. 

Synopsis: Wolff's Law. — Pott's Disease. — Torticollis. — Lateral Curvature of the Spine. — 
Rigid Spine. — Hip Disease. — Congenital Dislocation of the Hip. — Coxa Vara. — Knee 
Disease. — White Swelling. — Achillodynia. — Anterior Metatarsalgia. — Anterior Polio- 
myelitis. — Paralytic Club Foot. — Flat Foot. — Flat Foot of Children. 

WOLFE'S LAW 

In the normal state of health it has been found that the shaping of the 
parts of the body, and especially the bony system, is one of necessity and 
subsequent to the function expected from it. Julius Wolff, after many ex- 
periments and long research, has drawn the following conclusions: Any 
definite deviation in the relative position of a part of the human body to the 
whole will in time cause a static change in the inner architectural structure 
of the bone or bones entering into its support, this change advancing slowly 
until the new structure is mathematically and thereby functionally correct 
for the new position assumed. This inner change will in time also have an 
influence on the contour of the bone involved, thus altering its shape and 
making the same fit more readily its new relative position to the other parts, 
as well as its newly assumed function. In short, one may say that abnormal 
position of a part of the body demands a subsequent relative transforma- 
tion in the inner structure, contour, and physiological function of the bones 
supporting this part. 

POTT'S DISEASE 

Occurrence". — A tuberculous inflammation of the bodies of the vertebrae 
or of the intervertebral cartilages. It occurs most frequently in children. 
Of 1,000 consecutive cases of Pott's disease treated at the Hospital for 
Ruptured and Crippled (recently analyzed by Waterman and Jaeger) , 860 
were under ten years of age; 600 under five years of age. Children with a 
tuberculous family history are more liable to the disease. It frequently 
develops after some infectious disease, such as scarlet fever, measles, or 
pertussis. 

Traumatism is an serological factor in many cases. 

569 



570 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



Symptoms and Diagnosis. — The general symptoms are pain and reflex 
muscular spasm. The symptoms vary with the location of the disease. 




Fig. 178. — Bradford Carrying Frame for Pott's Disease. 



In disease of the cervical region, the head is held stiffly. The mus- 
cular spasm may hold the head straight or incline it slightly to one side, 
thus simulating torticollis. The child may be seen supporting its head with 

its hands — a valuable diag- 
nostic symptom. Interfer- 
ence with respiration caused 
by a postpharyngeal abscess 
may be the first symptom to 
call attention to the disease. 

In disease of the dorsal 
region pain is often referred 
to the front of the chest. 
Grunting respiration and 
night cries are early symp- 
toms, also an overcorrect- 
ness of posture or peculiar 
stiffness of the back, best 
seen when the child is asked 
to pick up something from 
the floor. 

In lumbar disease the 
pain is referred to the lower 
part of the abdomen or 
down the legs; the child also 
assumes an overerect pos- 
ture. There will be lordosis 
with consequent prominence 
of the abdomen, which may be the first noticeable sign of the disease. 
Spasmodic contractions of the legs are sometimes present. 




Fig. 179. — Bradford Frame. — Child able to Walk. 



POTT'S DISEASE 



571 



In all regions of the spine we find on examination reflex spasm of all 
the spinal muscles, causing rigidity of the spine on attempted motion in any 
direction. Angular deformity of the spine, or gibbus, is one of the later 
signs of the disease. Local tenderness may or may not be present. The 
patient walks with great care, instinctively trying to prevent jarring of the 
spine at each step. 

Differential Diagnosis. — From the spinal curvature of rickets. One can 
usually find other symptoms of rickets. The curvature is usually rounded 




Fig. ISO. — Pott's Disease Plaster Jacket and Headspring. 



and involves the whole spine. It is not angular, as in Pott's disease. The 
deformity may be reduced by placing the child on the abdomen and over- 
extending the thighs. 

Wry Neck. — Sudden onset, restriction of motion due to contracted 
muscle. Motion free and painless in all other directions. 

Hysterical Spine. — This usually occurs in neurotic adults. The spine 
is not rigid. 

Typhoid and Syphilitic Spine. — The history of the case helps to dis- 
tinguish it. 



572 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



Strain of the Back. — History of injury and sudden onset. 
Sciatica and Lumbago. — Rare in children. Pain restricted to the part 
affected. No spasm of spinal muscles. 

Hip Disease. — Disease in the lower lumbar region, with psoas contraction 
and pain in the leg, simulates hip disease. Motion of the hip is not limited 
except in extension. An abscess may be mistaken for perinephritic abscess 

or appendicitis; other signs of spinal 
disease are absent. If about the saphe- 
nous opening, it may simulate hernia. 

Therapeutics. — Let us take a typical 
case for an example: A young child, aged 
three, is brought for treatment soon 
after the onset of symptoms, with a very 
slight knuckle in the middorsal region. 
The first therapeutic measure would be 
fixation in the horizontal position on a 
Bradford frame (see illustration). 

The dimensions of the frame, its 
width, and the distance between the 
shoulder joints (in other words a little 
narrower than the child's body — this is 
very important as it has direct bearing 
on the thoroughness of the fixation) are 
such that it extends about five inches 
above the head and eight inches below 
the feet. The material is half inch gas 
pipe, and between the borders is tightly 
j stretched a canvas cover. At about the 
1 j place where the child's glutaei will come, 

m fl j the canvas is covered with rubber cloth 

ft fl to prevent soiling. At the point where 

^ fl j the deformity will rest, two narrow, 

I thick pads of felt are sewed to the can- 
fl fl i vas in the central line, about one inch 

■ fl ! apart. These pads press upon either 

W fl I side and have a redressing influence 

i upon the knuckle. The child is fixed 
upon the frame by means of a canvas 
apron strapped upon either side of the 
frame and extending from the upper 
part of the sternum to the lower part of 
the abdomen. 

After some weeks the child has be- 
come accustomed to this position, and we increase our efforts at over- 
extension of the spine by putting a sharp bend in the frame exactly 
where the gibbus is. The child is very easily taken care of in this frame. 
It can be carried about easily and taken out for an airing in a carriage, 
absolute fixation being secured without condemning the child to constant 
rest in bed. 




Fig. 181. — High Cervical Pott's Dis- 
ease, showing Characteristic Pos- 
ture or Child. 



POTT'S DISEASE 



573 



The duration of this treatment is measured by the progress of the case. 
As the child grows better it becomes livelier and makes attempts at crawling 
with the frame. The case shown in Fig. 176 was under treatment for seven 
months, and then the patient began to walk, as shown in the illustration. 
Now we are ready for the treatment by the plaster of Paris jacket. The 
first jacket is put on very thin, and, before it is thoroughly dry, the child is 
replaced on the frame and pressed down upon it, in this way continuing the 
superextension. The child now wears the jacket and frame for two or three 
months. The frame is then removed, the jacket is replaced by a slightly 
heavier one, and the child is allowed to walk around. If the parents can 




Fig. 182. — Spixal Tuberculous Abscess. 



afford it, a brace is applied at this time in place of the jacket. The most 
satisfactory brace is the Taylor brace as modified by Whitman, with acromial 
cups and shoulder pads. This brace or jacket is worn for one or more 
years. It is thus seen that in the most favorable case fixation treatment 
must be carried out for two years at least and possibly three, four, or five 
years. 

Should the disease be above the seventh dorsal vertebra, the child must 
wear a headspring or chin piece, as the jacket or brace alone will not give 
sufficient support in disease above the mid-dorsal region. The frame 
treatment cannot be applied to children above four years of age; in place 
of it a brace or jacket is applied at once. 



574 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



A little device employed by Lorenz, called "scratch band," adds greatly 
to the comfort of those obliged to wear a plaster of Paris jacket. This is 
made by placing a strip of strong China silk, about 8 inches wide and 1 
yard long, so that it will project from each end of the jacket under the 

shirt, before applying the jacket. 
This piece of silk is sewed up and 
down and around, every part of the 
torso coming in for its share of 
"scratching." The treatment of 
adult patients with Pott's disease is 
similar to the later stage of the 
child's treatment. A brace or plas- 
ter of Paris jacket is applied. 

The forcible reduction of the 
deformity of spinal disease, as ad- 
vocated by Calot, has been aban- 
doned as unscientific and entailing 
too great a risk for the patient, be- 
sides giving no permanent benefit. 
New bone will not form where the 
tuberculous process has once eaten 
it away. 

General hygienic treatment is 
of great importance in the manage- 
ment of these cases. Plenty of good 
food, outdoor life in the fresh air as 
much as possible, tonic medicines, 
everything that will increase the bod- 
ily welfare, will arrest the progress 
and hasten the cure of the disease. 

Complications. — Abscesses, as a 
rule, are treated conservatively. Ex- 
perience has not demonstrated the value of opening and draining. Aspira- 
tion of the abscess contents and injections of medicines, such as iodoform 
and glycerine, are successfully employed. This does not apply, however, to 
abscesses occurring in connection with cervical disease. These are usually 
postpharyngeal, and they point in the pharynx, interfere with respiration, 
and, if left to break spontaneously, may suddenly burst and discharge their 
contents into the larynx. Here an incision is called for. This is best done 
from the outside. The incision is made along the posterior border and 
upper part of the sternocleidomastoid muscle. 

In lumbar disease, where abscesses are more frecpient, we find them 
opening at the femoral ring. Psoas abscesses are sometimes aspirated with 
advantage, especially when they cause discomfort and deformity. Paralysis 
occurs in from 5 to 6 per cent of the cases. The best treatment is by fixation 
of the spine, and it is best accomplished by rest in the horizontal position 
on a Bradford frame. If the disease is high up, traction directly on the 
head with the weight and pulley is indicated. 

Spasmodic contraction of the limbs, which is painful and which so fre- 




Fig. 183. — Cervical Pott's Disease, show 
ing Characteristic Broadening of Neck. 



TORTICOLLIS 



575 



quently accompanies paraplegia, is best treated by weight and pulley traction 
on the limbs or a fixation brace. 

Potassium iodide should be given internally in gradually increasing 
doses. Massage is of value during the stage of recovery from paralysis; 
it is contraindicated during the presence of spasm. 



TORTICOLLIS 



Torticollis is an abnormal holding of the head, either constant or inter- 
mittent, toward one shoulder while the chin points toward the opposite 
side and upward. There are two 
varieties, congenital and acquired. 

The congenital form is rare and 
is caused by the head being held 
in a faulty position in utero or by 
injuries at birth during a difficult 
labor. Of the acquired, there are 
several forms. In the acute (rheu- 
matic) form the history is one of 
exposure and catching cold, sud- 
denly followed by pain and con- 
traction of one side of the neck. 
The spastic is the most common 
form. It is produced by anything 
causing an irritation of the spinal 
accessory nerve along its course or 
at its origin. Among these are 
burns, enlarged cervical lymph 
glands, quinsy, retropharyngeal 
abscess, tumors pressing on the 
spinal accessory, and infectious dis- 
eases. In the malarial form we 
may find at regular intervals in 
each year an acute spastic contrac- 
tion of the muscles. 

Symptomatic. — In cervical 
Pott's disease torticollis is often the 
first symptom. Then come hysteria, 
especially in women, and chorea. 

The differential diagnosis is eas- 
ily made from Pott's disease by the 
character of the deflection of the 
head, the absence of pain, and the 
freedom of motion in other direc- 
tions. 

Symptoms. — The characteristic 
picture of the chronic type is that the head lies to a great extent over the 
thoracic half of the healthy side, being drawn toward the side of the con- 
tracted muscle, whereas the face is drawn to the opposite side and the chin 




Fig. 184. — Pott's Disease, showing Kyphos 
and Abscess. (Hospital for Ruptured and 
Crippled, N. Y.) 



576 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



points upward. By measurement one finds one sternocleidomastoid muscle 
shorter than the other. On palpation the muscle is tense. By active 
movement of the healthy side it is possible to bring the face over the 
shoulder. Capability of movement of the head to the affected side is only 

very slight actively, and 
only to a small degree pas- 
sively. There is usually 
asymmetry of the face. In 
acute cases we find local pain 
and tenderness, with great 
sensitiveness on an attempt 
to correct the deformity. 

Treatment. — In mild 
cases regular manipulation 
and stretching of the con- 
tracted muscles and tissues, 
combined with massage and 
vibratory massage, will 
bring about a cure. 

In the acute form, with 
pain and spasm, counter- 
irritation and some form of 
support to hold the head in 
proper position are indi- 
cated. The simplest is a 
collar composed of cotton, 
a couple of roller bandages 
tightly wound about the 
neck and reenforced with 
adhesive plaster. 

It is rarely necessary to 
apply a plaster of Paris 
jacket, with which is in- 
corporated the jury mast. 
In the chronic stage, or stage 
of simple deformity, one 
must resort to tenotomy, 
either subcutaneous or 
open, of the contracted 
muscles and the applica- 
ble. 185— Applying Plaster of Paris Jacket. tion of a plaster of Paris 
(Taylor, the Medical News.) dressing inclosing the head 

and shoulders, the head 
being forcibly overcorrected. This dressing should remain for from six to 
eight weeks and be followed by massage and gymnastic exercises to prevent 
recurrence. 

LATERAL CURVATURE OF THE SPINE 
This is an habitual deviation of some part of the spinal column from 
the normal median line. 




LATERAL CURVATURE OF THE SPINE 



577 



Etiology. — Heredity is a factor in the aetiology. The tendency to 
weakness of the muscles, which favors deformity, is inherited. Occupa- 
tions which demand or favor a faulty position of the trunk are indirect 
causes. In school children the practice of carrying heavy books with one 
arm and a faulty position while sitting at the desk, combined with confine- 
ment and lack of exercise, favor the production of the deformity. The 
direct cause is the force of gravity acting on the weakened spine. It is 
much more common in girls than in boys; the proportion is four to one 
(Whitman). It is a condition of early adolescent life. 

Diagnosis. — Very frequently the parents' attention is first drawn to the 
condition by noticing one shoulder higher than the other or one hip more 

prominent. The diagnosis is read- 

ily made by examining the nude 
back, when the deviation is seen. 
The rotation of the vertebrae which 
usually accompanies the lateral 
curve is best seen by having the 
patient stand before one, facing the 
windows and bending the body for- 
ward, the arms and head hanging 
down. 

There are two curves — a pri- 
mary and a secondary, or compen- 
satory, curve, giving the spine the 
shape of the letter S or an inverted 
S. The dorsal region is most fre- 
quently the seat of the primary 
curve, and the curve is most fre- 
quently to the right. 

Pain is very rarely a symptom 
in the younger patients, being usu- 
ally found only in adults and in 
cases with very marked deformity. 
In these cases there may be present 
symptoms due to pressure on in- 
ternal Organs, such as the heart, FlG . 186.— Torticollis showing Facial 
limgS, Or liver. Asymmetry. 

The varieties are the habitual 
(the most frequent), the rhachitic, the static, the congenital, the cicatricial, 
the empyemic, the nervous, the traumatic, the rheumatic, the neuromus- 
cular, and the sciatic. Rhachitic deformity of the spine usually takes the 
form of a posterior curve, but in rare cases we observe a lateral curve. 
The principal differences are that it is seen at an earlier age, and shows 
usually one long curve, and that there are other evidences of rickets 
present. 

• The static form is due to difference in the length of the legs, which causes 
an inclination of the pelvis toward the short leg and consequent curve of 
the lumbar vertebrae. A large number of patients with lateral curvature 
have a difference in the length of their legs. The cicatricial, empyemic, 





578 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



ischiadic, traumatic, and rheumatic forms are secondary to the primary 
disease or injury. 

The congenital form is rather rare, but it does occur. 
Hysterical scoliosis is seen in nervous patients who present other signs 
of hysteria. It disappears under narcosis. 

The paralytic form occurs after anterior poliomyelitis, cerebral paralysis, 
progressive muscular atrophy, and other nervous diseases. This presents 
usually only one long curve, which rarely becomes fixed. 

Treatment. — Massage of the muscles of the back and appropriate exercises 
to strengthen them. By placing the child in a proper attitude and by its 

frequently practising to assume this 
attitude, it will gradually retain it. 
Two or three exercises that have a 
redressing influence upon the curva- 
ture may be taught the child, with 
instructions to practise them daily. 
Two exercises well carried out are 
better than a dozen poorly executed. 
1. Have the patient stand straight, 
with the heels together and the toes 
apart, and take a deep breath. 2. 
The patient places one foot (the foot 
on the same side as the convexity 
of the dorsal curve) slightly forward 
and outward, and then bends the 
knee ; this reduces the lumbar curve. 
He now places one hand on the 
highest point of the deformity and 
the other hand on the back of the 
neck (see illustration) , and pulls and 
presses to reduce the dorsal curve. 
The two motions are done in unison. 
First command: To bend the knee 
and press on the hump. Second 
command: To straighten the knee 
and relax the pressure on the hump. 
Another exercise : The patient stand- 
ing straight, with the heels together 
and the knees extended, one arm 
(the one corresponding to the side 
of the concave dorsal curve) is 
raised straight up and held close to 
the ear, and the other arm is raised 
to the horizontal position; the pa- 
tient now, without bending the 
knees, bends the body slowly for- 
ward and back again. Another ex- 
ercise: The patient, lying face down on a couch, places both hands behind 
the neck and, an attendant holding the feet down, the patient raises the 




Fig. 187. — Scoliosis. 



RIGID SPINE; SPONDYLITIS DEFORMANS 



579 



trunk upward (or up from the couch). This is repeated from ten to 
twenty- five times. 

The more severe cases, especially in adults, are often accompanied by 
pain. It is then necessary to provide a brace or plaster of Paris corset. 
The principle of the treatment is 
to mobilize the spinal column first, 
then to reduce deformity as much 
as possible by strengthening the 
muscles and training the patient to 
hold the body in this corrected 
position. 

RIGID SPINE; SPONDYLITIS DE- 
FORMANS (SPONDYLOSE RHI- 
ZOME'LIQUE) 

This is a chronic ankylosing in- 
flammation of the spine character- 
ized by local pain, stiffness, and 
deformity. The pathological fea- 
tures are atrophy of the interver- 
tebral discs and periosteal pro- 
liferations and thickenings with 
ossification, particularly on the 
anterior and lateral aspects of the 
spine. On account of these bony 
proliferations firm bony unions — 
synostoses — form between the ver- 
tebrae and they extend gradually 
to the whole spine. Together with 
these bony changes we observe 
atrophy of the muscles and a grad- 
ual forward bending of the spine. 
As ^etiological factors may be con- 
sidered trauma, the continued 
carrying of heavy burdens, and in- 
fectious joint inflammations, such 
as gonorrho?al arthritis and poly- 
articular rheumatism. 

Schlesinger has described a 
form of ossifying spondylitis which 

he considers to be due to a local disease of the intervertebral ligaments, the 
development of which is most probably favored by a congenital disposi- 
tion to excesses in bony growth. 

Symptoms. — The symptoms are pain of a rheumatic character, pain in 
the loins and radiating forward, a diminishing mobility of the spine ending 
in absolute stiffness, and a marked forward bending of the entire spine. 

Neuralgias occur, probably from bony encroachments on the nerve roots. 

Treatment. — The application of a brace or plaster of Paris corset, massage 
to the back, and the cautery at regular intervals. In the early stages, 




Fig. 188. — Exercise for Scoliosis. 



580 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



rubber heels and self-suspension add greatly to the comfort. Regulate the 
diet (antirheumatic) and order general outdoor exercise and tonics. 

HIP DISEASE 

This is a tuberculous disease of the joint structures of the hip, usually 
beginning at the femoral head, less frequently in the acetabulum and 
synovial membrane. The causes are predisposing and exciting. Among 

the first are reduced vitality, as after 
infectious diseases, injury, and a family 
history of tuberculosis. The exciting 
cause is the presence of the tubercle 
bacillus. It is most common in early 
life and more frequent among boys than 
girls. 

Diagnosis. — As in tuberculous dis- 
ease in other joints, an early diagnosis 
is very important. The early symp- 
toms are fatigue in the affected leg on 
slight exertion and a limp. Pain is 
rarely complained of in the early stage, 
and when it is present it is usually re- 
ferred to the knee. If the disease is 
progressing rapidly, there are night 
cries; the child screams suddenly dur- 
ing profound sleep, wakes for a few 
minutes, and then falls asleep again. 
The night cries are due to a sudden 
movement of the hip, causing an invol- 
untary contraction of the hip muscles 
and thus producing pressure on the in- 
flamed parts. Lameness in the begin- 
ning of the disease is not a constant 
symptom, being present for some days 
and absent again. The patient walks 
by stepping on the ball of the foot 
rather than on the heel; the knee and 
(Hospital for Ruptured and Crippled.) j^p are held slightly flexed and the thigh 

slightly adducted. There is usually 
some stiffness in the morning, which, together with the limp, passes away 
toward evening. A physical sign observed on examination is stiffness due 
to reflex spasm of the muscles which contract and hold the hip joint when 
motion is attempted beyond a certain point. 

Malpositions of the Limb. — Adduction and flexion are caused by muscular 
spasm and become permanent by the changes in the joint and contrac- 
tures of the surrounding soft parts. Outward rotation also occurs in the 
early stage. As the disease progresses, the flexion becomes greater and the 
limb becomes adducted and rotated inward. Atrophy becomes manifest 
early in the history of the disease. It is caused partly by disease and reflexly 
through the nervous irritation of the joint disease. 




HIP DISEASE 



581 



Shortening is of two kinds, real and apparent. The real shortening 
is the result of destruction of the bony parts entering into the joint structure, 
with consequent upward displacement, and secondly to the atrophy. Ap- 
parent shortening is due to the malposition of the limb. 

Abscess is present in a large proportion of cases, particularly in those 
cases which have had inefficient treatment or none at all. Its usual site 
is upon the upper and outer aspect of the thigh. 

Differential Diagnosis. — Pott's disease, low lumbar disease with psoas 
contraction, simulates hip disease, but may be excluded when the range of 
motion is limited in all directions. In Pott's disease motion is restricted 
only in the line of extension by the contracted ilio-psoas muscle. In coxa 
vara the trochanter is above Nelaton's line; motion is not painful and is 
restricted only in abduction. Sprains and acute synovitis are excluded by 
their sudden onset and the history of injury. In congenital dislocation 




Fig. 190. — Bed Extension in Hip Disease. 



of hip the patient has a limp, characteristic of dislocation. There is no pain, 
and motion is free in all directions. 

Treatment. — The cardinal point in the management is, as in other tuber- 
culous joint affections, that of rest and fixation. Constitutional treatment 
is an important adjunct to the mechanical. It is important to reduce any 
deformity that may exist before applying fixation treatment. This may be 
accomplished by traction applied by the weight and pulley (see illustration) 
while the patient is in bed. Or the reduction may be gradually attained 
by successive plaster of Paris dressings, the leg being put in the best possible 
position at each sitting. Or forcible reduction may be done under narcosis 
and a plaster of Paris spica applied to maintain the corrected position. 

The leg being in good position, some form of retentive apparatus is now 
applied. The best brace is the one designed by Hessing. It insures abso- 
lute fixation of and protection to the hip joint, besides permitting free 
motion of the knee and ankle joints, thus obviating to a certain extent the 
evil after effects of total fixation, namely, muscular atrophy from disease 
and shortening from interference with the circulation of the limb. It is 
worn under the clothes and is hardly noticeable. It consists of a pelvic 
portion, which is carefully moulded upon the pelvis, holding it perfectly 



582 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



rigid; to this is attached the leg portion, or so called shell splint. The 
leather shells are jointed on the inner and outer sides by two light steel 
splints, and are laced about the thigh, leg, and foot. The steels have free 
joints at the knee and ankle. At the upper and inner part of the thigh the 
shell has a broad padded surface upon which the ischium rests, and a lac- 
ing passes around the ankle to produce extension. It is not necessary to 
wear a high shoe on the foot of the sound side. 

A very efficient brace is the so called traction hip splint. It consists of 
a pelvic band made of a short steel about an inch and a quarter wide and an 
eighth of an inch thick and bent to a U shape. This is made long enough 
to go three quarters of the way around the pelvis. To this is attached a 
long steel bar which extends down the leg and about two inches and a half 
below the foot. 

The pelvic band is strapped around the body and serves as a support for 
two perineal straps and also for an upright bar, about five inches long, 
to which is attached a similar band which encircles the thorax. This latter 
insures better fixation and lessened danger from flexion deformity at the hip. 
The leg stem is provided with a strap at the knee joint for holding the 
leg firmly to the brace. The patient wears on each side of the leg adhesive 
plasters (best made of mole skin). They extend to an inch above the 
malleoli and are provided at the lower ends with buckles. Two straps 
attached to the foot piece of the brace and inserted into the buckles produce 
traction on the leg. 

A high shoe (cork sole) is worn on the healthy side. For adult cases and 
for mild types of cases in children, the Lorenz spica is a convenient and 
simple retentive apparatus. The spica is modelled very accurately around 
the pelvic bones, thus getting a firm and steady hold. Extending only to 
the knee, it allows of freedom of motion of all the joints except the diseased 
hip. Often it is found useful to combine a light plaster spica with the long 
traction splint, if the joint is very sensitive and the patient does not seem 
to progress favorably. 

The duration of the treatment is in the most favorable case two years 
and may be from three to seven years. The child should remain under 
the observation of the physician for a considerable period after an apparent 
cure. 

When the active symptoms, pain and muscular spasm, subside, and the 
disease is apparently cured, we apply a convalescent hip brace. This is 
the ordinary traction splint with the thoracic band removed and about 
two inches of its lower end cut off and fastened to the heel of the shoe. When 
the brace is applied, the patient's heel should not quite touch the bottom 
of the shoe, thus protecting the hip joint. 

As the patient progresses the brace is removed at night and then for 
short periods during the day, gradually weaning the patient from its use. 

Treatment of Complications. — Abscesses are treated expectantly. 
Even large abscesses may be absorbed. If they are very large and painful and 
show a tendency to rupture spontaneously, it is best to empty the abscess 
by aspiration, or one may incise under the strictest aseptic precautions, mak- 
ing a free incision, curetting out the abscess wall, and sewing up the wound 
completely. Primary union frequently follows this procedure. In cases 



CONGENITAL DISLOCATION OF THE HIP 



583 



with long continued suppuration a more radical treatment may be indicated 
and then we do an excision of the hip joint. 

CONGENITAL DISLOCATION OF THE HIP 
This is more frequent than congenital dislocation of any other joint. 
Etiology. — It is most common in females, occurring in them in about 
85 per cent of the cases. One side is affected more frequently than both 




Fig. 191. — Lorenz Spica. 



(about 70 per cent of the former and 30 per cent of the latter). Defective 
development of the acetabulum and abnormal laxity of the capsule are pre- 
disposing causes. The dislocation is usually dorsal, but in rare cases it is 
anterior, the head being under the anterior superior spine of the ilium. 
38 



584 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



Symptoms. — The condition is usually first recognized when the child 
begins to walk. If only one hip is dislocated, there is a peculiar limp; at 
each step the body is thrown toward the affected side, a sort of lunge forward 
and sideways. The affected leg is shorter than the other and becomes 

shorter (the femoral head slid- 

Iing upward) at each step. The 
trochanter is above Nelaton's 
line. As to the subjective 
symptoms, the child tires eas- 
ily and as it grows older has 
pain on exertion. There is dis- 
inclination to walk. The par- 
ents may notice a lump on the 
buttock, which is the displaced 
head- of the femur. In bilat- 
eral dislocation the patients 
walk with a peculiar ducklike 
waddle, the body lunging from 
one side to the other at each 
step. The disability in these 
cases is more marked. There 
is also a marked prominence 
of the buttocks and there is 
lumbar lordosis. 

The diagnosis is easily 
made. A physical examina- 
tion reveals the head of the 
femur in an abnormal place. 
There is no pain or spasm on 
motion, which is free in all di- 
rections, and the condition can- 
not possibly be mistaken for 
tuberculous disease of the hip joint. Coxa vara, although in this condi- 
tion the trochanter is above Nelaton's line, is excluded by finding the head 
of the bone in its proper place and by the limitation of motion in the direc- 
tion of abduction. 

Treatment. — The work of Lorenz and Hoffa has resulted in a marked 
change of opinion on this subject, and we are able to give a good prognosis 
for cure when formerly nothing could be done for these cases. Bloodless 
reduction, or the Lorenz method, consists in reducing the dislocation under 
ether and holding the limb in position by means of a plaster of Paris cast 
until the stretched capsule and soft parts have contracted and the head has 
secured a firm hold in its normal position. 

The details are as follows: Under ether the resistance of the soft parts 
(the adductor and extensor muscles) is first diminished; this is done by 
forcibly abducting the leg in an intermittent manner, and with the ulnar 
border of hand forcibly massaging the adductor muscles at their insertion 
into the pelvis. The leg is now pulled upon to bring the head of the femur 
to the level of the acetabulum, an assistant applying countertraction at 




Fig. 192. — Double Spica after Reduction of 
Double Congenital Dislocation of Hip 
(Lorenz). 



CONGENITAL DISLOCATION OF THE HIP 



585 



the perinauim by means of the hand or a sheet passed under the perinseum 
and having the two ends tied to the head end of the table. Traction is now 
intermittently applied until the soft parts are relaxed. The reduction 
manoeuvre proper is now carried out. The leg is grasped with one hand 
above the knee, and flexed, rotated outward, and abducted. Motions like 
those of a pump handle, but in the horizontal direction, are now carried out, 
and while the leg is held in the aforesaid position of flexion, rotation outward, 
and abduction, the knee is gradually brought behind the plane of the body 
(superextension). The other hand is placed in the groin, the thumb upon 
the trochanter, the fingers next to the genitals, and pressure inward is 
exerted upon the trochanter. In older children the surgeon's fist or a 
padded wedge may be used as a fulcrum upon which the trochanter rests; 
the head of the bone is then forced over the edge of the acetabulum. These 
manoeuvres having been properly and consistently carried out, the head 
will pop into the acetabulum with an audible snap. 

The next important part of the treatment consists in retaining the head 
in its desired position, Lorenz's theory regarding the success of the treat- 
ment being that the constant impaction of the femoral head in the ace- 
tabulum while walking will cause a deepening of the usually shallow 
structure and give a firm hold to the joint. It will be noticed that 
while the limb is abducted the head remains in place, and when the leg 
is adducted the dislocation recurs; consequently we apply a plaster of 
Paris dressing in the position strong enough to assure a firm hold in 
the acetabulum: this Lorenz calls the indifferent middle position. The 



r 




Fig. 193. — Lorenz Hip Redresseur. 

original dressing is retained for from three to six months, depending 
largely upon the cleanliness. It is then removed, and the leg is very 
cautiously adducted a little in order to make locomotion easier and to 
insure the stability of the joint in the straightest position, and another 
dressing is applied. This is worn for two or three months. A cork 
sole is applied to the shoe of the side that has been operated on, in 
order to even out the difference in the length of the legs. A third spica 



586 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



may be applied with the leg in a straight position and retained for two or 
three months. 

The operation is not absolutely free from risk, for by too forcible manipu- 
lation there may occur a fracture of the neck of the femur or of the ramus 
of the pubes, paralysis of the sciatic and crural nerves, and other injuries 
of the soft parts. In bilateral cases both sides may be operated upon at one 
sitting. 

The most favorable age at which to perform the operation is under six 
years, although in unilateral cases patients have been operated upon suc- 
cessfully as late as ten years of age, 
while eight is about the limit in bilateral 
cases. 

The bloody method consists in deep- 
ening the acetabulum and then replac- 
ing the head. The operation may be 
performed after the bloodless one has 
been tried without success. Lack of 
success is often due to distortions of the 
head and neck of the femur, and it is 
often necessary to do a subsequent os- 
teotomy at the upper end of the femur, 
causing the bone to heal in as good a 
position as possible. 

COXA VARA 

This consists in bending of the neck 
of the femur, usually in a downward and 
backward direction. It is a deformity 
analogous to knock knee or bow leg. 
It occurs in late childhood and adol- 
escence. It is more often unilateral 
than bilateral. 

Etiology. — "It is one of a group of 
static deformities caused by a dispropor- 
tion between the strength of the sup- 
porting structure and the burden that is 

Fig. 194.— Coxa Vara. P^t upon it" (Whitman). 

Showing elevation of trochanters. Fracture of the neck of the femur in 

childhood is often followed in later 
years by coxa vara. Males are affected three times as frequently as females. 
Rhachitis is an setiological factor. 

Symptoms. — Pain or discomfort in the hip joint and thigh, especially after 
overexertion, with a limp. There is shortening of the affected limb amount- 
ing to an inch or more; this is due to the change in the angle of the neck to the 
femur, the trochanter being an inch or more above Nelaton's line. Limita- 
tion of motion in the direction of abduction, inward rotation, and flexion. 

In bilateral coxa vara the symptoms are more pronounced, the abduc- 
tion of both thighs obliging the patient to sway the body from side to side 




KNEE DISEASE 



587 



at each step, as in knock knee, to permit the legs to pass — the so called 
scissors walk. In extreme deformity the limbs are actually crossed. 

The symptoms last a varying period, from one to three or more years, 
and usually end when the bones are completely ossified. 

Diagnosis. — From hip disease, by the absence of severe pain and mus- 
cular spasm; by motion not being limited in all directions; by shorten- 
ing and elevation of the trochanter above Nelaton's line, which is pres- 
ent very early in this affection, coming later, with the destruction of 
bone, in hip disease. From congenital dislocation, by our not being 
able to feel the femoral head out of its normal position and by limita- 
tion of motion, which is free in dislocation of the hip. Coxa vara is not 
present at birth. 

Treatment. — Constitutional treatment is important in the early stages, 
with attention to diet, gymnastic exercises, massage, and avoidance of over- 
strain. A brace should be worn to take the weight off the disabled limb; 
a form of brace similar to the convalescent hip splint, which may have a 
joint at the knee, is very useful. This should be worn for a year or more. 

An operation is indicated when great deformity exists. A linear oste- 
otomy just below the trochanter minor is performed and the limb rotated 
inward and abducted. A plaster of Paris spica is now applied, or a cunei- 
form osteotomy at the upper end of the shaft, with a view to restoring the 
proper angle to the neck of the shaft, is indicated in young patients. 

KNEE DISEASE (WHITE SWELLING) 

Tuberculous inflammation of the structures of the knee joint. It is an 
osteitis of the epiphysis beginning in either femoral or tibial epiphysis, less 
frequently in the synovial membranes. Another variety begins as a sim- 
ple synovitis, the early symptoms of which are subacute, the condition 
becoming chronic, with thickening and infiltration of the sac. 

The symptoms are those common to other tuberculous joints, namely, 
joint tenderness, muscular spasm, deformity, and in addition distention of 
the joint, heat, and swelling. Atrophy of the muscles comes on later in the 
course of the disease. There are pain and local sensitiveness. Shortening- 
is not present at first ; on the contrary, there is usually lengthening of the 
leg, due to hypersemia and increased growth at the epiphysis. This in- 
creased growth, however, gives place to atrophy after the disease is cured, 
and almost all the patients recover with a shortened limb. 

Frequently the inner condyle enlarges to a greater extent than the outer, 
thus causing knock knee. The pain is rarely severe, and night cries are 
not a common feature of the disease. If the condition is progressing rapidly 
or if there is an acute exacerbation or if the patient receives a fresh injury, 
the joint will be painful. Muscular fixation is a prominent symptom, the 
joint being fixed in slight flexion. Malpositions of the limb are flexion, 
rotation outward of the tibia on the femur, and subluxation of the tibia 
backward. 

The synovial varietv of the disease is found usually in adults, and it 
be gins as a simple subacute synovitis. The condition goes on for years 
without marked symptoms, but there will be a thickening of the synovial 



588 OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 

capsule, very slight limitation of motion, a gradual thickening of the bones, 
and occasional attacks of pain. 

. Differential Diagnosis. — In rheumatism, usually more than one joint is 
affected, and the onset is sudden and accompanied by constitutional symp- 
toms. A sprain has a sudden onset, with a history of injury and rapid 
recovery. In Charcot's disease there is the presence of tabes dorsalis, with 
sudden effusion into the knee and rapid destruction of the joint. The 

hysterical joint occurs in a neurotic pa- 
tient, and there is absence of physical 
signs. 

In sarcoma the disease extends ra- 
pidly and is not influenced by treatment. 
The x rays are of great value in the dis- 
tinction. 

Treatment. — In childhood the treat- 
ment is conservative, because the prog- 
nosis is favorable as to cure of the dis- 
ease and as to functional use. More- 
over, an operation which would destroy 
the epiphysis would prevent further 
growth of the leg and cause great defor- 
mity by shortening in later years. In 
adults, where it is desirable to bring 
about a cure as quickly as possible and 
where, on account of full development, 
excessive shortening of the limb is not 
to be feared, excision of the joint with 
ankylosis is most advisable. 

If any deformity exists, this must 
first be corrected, so that when healing 
takes place the leg will be in good posi- 
tion, namely, that of extension. The 
flexion deformity may be corrected by 
rest in bed and traction applied to the 
leg. Or one may apply a plaster of 
Paris bandage, with an assistant making 
strong traction on the leg during the 

Fig. 195.— Bow Legs and Congenital application of the bandage. It may be 

Deformity of Upper Extremity. necessary to give an anaesthetic. The 

leg being straight, a well fitting brace 
is now applied to take the weight of the body from the diseased knee. The 
Thomas brace fulfils all the demands for utility and simplicity. It consists 
of an iron ring irregularly ovoid in shape, in order to fit the thigh snugly 
at the perinaeum, to which ring are fastened two upright bars which go 
down each side of the leg and extend two or three inches below the foot, 
where they are joined. The circular leather bands support the leg at the 
thigh and calf and the knee is still further fixed by being bandaged snugly 
to the brace. A high shoe, cork sole, or patten is worn on the sound foot. 
It is customary to increase the usefulness of the Thomas brace by com- 




ANTERIOR METATARSALGIA 



589 



bining traction by means of adhesive plaster applied to the leg up to the 
knee joint, terminating in straps which are buckled to the foot piece of the 

brace. If the symptoms are very 

acute, crutches may be used in 
addition to the brace, and a very 
light plaster of Paris cast be ap- 
plied to the knee before putting on 
the brace. 

While acute symptoms are 
present, the brace is worn night and 
day; after a number of months, 
when the acute symptoms have 
subsided, i. e., the muscular spasm 
and pain, etc., the brace may be 
left off at night, carefully watch- 
ing the patient for recurrence. 
As the patient improves the brace 
may be removed for a few hours 
each day. The caliper brace may 
now be substituted; the two bars 
are cut off, turned inward at a 
right angle, and fastened to the 
heels of the shoes. The bars are 

made a little longer than the leg, so that the heel does not touch the 
bottom of the shoe when the patient is walking. 

Abscesses, if large and superficial, are to be treated by incision and 
drainage. Sinuses may be curetted, and in cases of long standing suppu- 
ration, excision or arthreotomy may be indicated. Amputation may be 
necessary in very bad cases. 

For Knock Knee and Bow Legs see Pediatric Section (Rhachitis). 




Fig. 190. — Knock Knee. 



ACHILLODYNI A 

This is an inflammation of the bursa lying between the tendo A chillis 
and its insertion into the os calcis. 

etiology. — Strain or injury, usually caused by pressure of shoe. Rheu- 
matism, gout, or gonorrhoea is often the apparent cause of the condition. 

Symptoms. — Pain in the back of the heel, aggravated by use of the foot. 
Local tenderness on pressure; swelling. 

Treatment. — Hot air, massage, strapping with adhesive plaster to make 
pressure over the bursa. In severe cases a plaster of Paris cast. A rubber 
heel to soften the jar of each step. In chronic cases removal of the bursa 
by surgical procedure may be indicated. 



ANTERIOR METATARSALGIA 

Also called Morton's painful affection of the foot. Depression of the 
anterior arch. 

It is a neuralgic pain in one of the phalangeometatarsal articulations, 
most frequently the fourth. It is a condition of adult life. It is usually 



590 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



unilateral, the second foot becoming affected later. Women are most 
frequently affected. This has a direct bearing on the aetiology, namely, 
the wearing of improperly shaped shoes. It is often associated with flat foot. 
Gout, rheumatism, and general debility are factors in the aetiology. Ner- 
vous people also are prone to it. 

The symptoms are paroxysms of severe neuralgic pain in the front of the 
foot, followed by a long continued dull ache and sometimes slight swelling. 
There is local sensitiveness to pressure. The pain is usually felt only when 
wearing shoes. The pain is not to be explained by the direct lateral pressure 
on the sunken anterior arch. 

Treatment. — A proper shoe of ample width and with a thick sole and a 
high arch and low heel. If this does not suffice, a metal plate similar to the 
one used for flat foot, but continued further forward and with an arch under 
the heads of the metatarsal bones, is to be worn inside the shoe. Temporary 
relief is obtained by circular strapping of the front of the foot with adhesive 
plaster, with a small round pad of felt or leather under the anterior arch. 

ANTERIOR POLIOMYELITIS AND PARALYTIC CLUB FOOT 

Anterior poliomyelitis is an acute inflammatory disease of the anterior 
horns of the spinal cord, occurring chiefly in children and resulting in 
paralysis, more or less complete, of one or both lower extremities. It occurs 
most frequently in children under the age of five and during the warm 
months, June to September. The fact that sometimes two children in one 

family or several children 
in a neighborhood are at- 
tacked with the disease at 
the same time leads one to 
think of it as an infectious 
disease of microbic origin. 
It also occurs in epidemic 
form. 

Symptoms. — The onset 
is very sudden; a child 
perfectly well is attacked 
with fever, gastric disturb- 
ances, and sudden paraly- 
sis, or, going to bed in per- 
fect health, wakes up the 
next morning and finds 
Fig. 197.— Club Foot. that it cannot move. The 

(Hospital for Ruptured and Crippled.) lower limbs alone or all 

four extremities may be 
paralyzed. The arms quickly recover their power. The paralysis leaves 
the legs more slowly, some muscles remaining permanently palsied. If the 
destruction in the nerve centres has been very great, the muscles never re- 
cover, the nutrition and growth of the bones of the affected limb are seri- 
ously interfered with, and as time goes on the limb may become many 
inches shorter than the other. The reflexes are lost. The skin of the feet 




ANTERIOR POLIOMYELITIS AND PARALYTIC CLUB FOOT 591 



becomes bluish and the extremities are cold from impaired circulation, due 
to loss of innervation. Sensation is not lost. 

The diagnosis is usually not made until the paralysis has set in. 

The treatment of the acute stage must be as energetic as possible, with 
a view to limiting the inflammation in the spinal cord and the consequent 
destruction of the nerve centres. It includes counterirritation to the spine, 
the application of cold in form 
of ice bags over the spine, and 
placing the patient on the ab- 
domen to lessen congestion. 

After the inflammation has 
subsided and the chronic stage 
has set in, it is very important 
to begin to exercise the muscles 
passively and actively and to 
employ massage and electricity. 
The Krukenberg pendulum ap- 
paratus is invaluable in the 
treatment of these paralyzed 
muscles; with its aid, even very 
young children can, with the 
employment of a little tact, be 
made to exercise regularly. Par- 
ents should be instructed how to 
manipulate the limbs in order 
to overcome the tendency to 
deformity caused by the unop- 
posed action of the healthy 
muscles. 

It is a great mistake to apply 

braces immediately, for, while p IG . 198.— Talipes Equinus from Infantile 
they may hold the limbs in a Paralysis. Girl fourteen years. 

straight position, they cause 

considerable atrophy of the muscles on account of interference with their 
use and on account of the pressure of the straps and bands making up the 
brace. When the muscles have recovered their power as much as they can, 
it may become necessary to apply a brace to prevent deformity caused by 
the action of the unopposed muscles and by the force of gravity (toe drop). 
The kind of brace used will vary according to the extent of the paralysis, 
a simple upright bar extending to the knee and afoot piece being sufficient 
for light cases of toe drop or valgus, or double upright bars extending to the 
hips, with a band about the waist and no joint at the knee or ankle, will 
be of considerable aid in walking where the thigh and leg muscles are both 
affected. 

A form of treatment extensively used and of growing importance is 
tendon transplantation. The idea of this surgical intervention is to transfer 
the power of a strong, active muscle to a paralyzed one, and to make it do 
the work of the paralyzed muscle. This operation is of great value when the 
limb is only partly paralyzed and there remain some healthy muscles which 




592 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



can be spared from their original purpose and grafted upon some other 
muscle. In combination with the transplantation, we can also effect a 
lengthening or shortening of muscles, and it is by the combination of these 
three methods that the best results are obtained and a cure brought about 
which formerly was impossible. As examples of the classes of cases in 

which it may be employed, the 
following are given: In para- 
lytic pes calcaneus, the pero- 
neal muscles are sewed on to 
the shortened tendo Achillis. 

In paralytic pes valgus with 
passive lengthening of the ti- 
bialis anticus muscles, the ten- 
don of the tibialis anticus is 
divided, the foot placed in a 
highly overcorrected position 
(varus), and the cut ends 

Fig. 199.— Talipes Calcaneus. strongly pulled together and 

sewed. Then a splice from 
the tendo Achillis or from the peroneus longus may be sewed on to the 
tibialis anticus or posticus. 

Paralytic Club Foot. — In shortening of the tibialis, anticus, if necessary 
a splice of the tendo Achillis may be sewed upon the paralyzed peroneus 
longus or the extensor longus digitorum communis. 

In paralysis of the quadriceps femoris, the sartorius has been success- 
fully transplanted upon the paralyzed quadriceps extensor femoris. After 
the operation is completed, the limb is placed in an overcorrected position 
in a plaster of Paris bandage and retained there for from four to six weeks. 
The after-treatment consists of massage, gymnastics, and electricity, and 
the wearing of a retentive apparatus for some months to prevent recurrence. 
In severe cases, arthrodesis, or removal of the ankle joint, is indicated, as a 
stiff foot is preferable to the flail joint and furnishes proper support to the 
body. 

FLAT FOOT 

Flat foot is that deformity in which the foot is held fixed in the pronated 
and abducted position. According to Whitman, who proposes the term 
weak foot, it is one in which the attitude of rest or inactivity persists. The 
weight of the body falls upon the internal border of the foot and it is sup- 
ported to a great degree by the ligaments. 

There are several varieties. The congenital is due to pressure upon the 
foot in a faulty position in utero; it is not uncommon. 

The acquired, traumatic form follows sprain, luxation, or fracture of the 
bones of the ankle joint. It is the usual result of badly set fractures of the 
lower extremity of the tibia or fibula. 

The paralytic form is due to paralysis of the plantar flexors and supi- 
nators of the foot, following anterior poliomyelitis, cerebral paralysis, etc. 

The rhachitic form is due to bearing weight on the softened bones, and is 
seen very frequently in connection with knock knee. 




FLAT FOOT 



593 



The static flat foot is the most important variety. It occurs most fre- 
quently in young adults, more especially males, among those who are obliged 
to stand a great deal or to carry heavy weights. In long continued standing, 
in order to take the strain from the muscles which assist in holding up the 
arch, the patient assumes the attitude of rest. He abducts the limbs 
slightly (spreads them apart), rotates the legs a little outward, slightly flexes 
the knees, and holds the feet strongly abducted. In this position the weight 
of the body falls on the inner border of the foot and the ligaments alone sup- 
port the arch. The deformity is caused by reflex muscular spasm, which 
in time holds the limb in a false attitude. Flexion in the astragalotibial 
articulation with extension in the mediotarsal joints is the earliest position 
of deformity, and it is soon accompanied by abduction and pronation. 

Symptoms. — In the earliest stages there are no objective symptoms, 
and we must be guided entirely by what the patients say. The patient 
notices that he tires easily; he usually complains of one foot first, for the 
condition rarely begins in both feet at the same time. The fatigue is felt, 
not in the foot, but in the calf muscle; this then increases as a feeling of 
tension and stiffness in 
the calf, a dull ache. 
Then, after a greater 
exertion or long stand- 
ing or walking on hard 
floors or a pavement, 
this feeling extends 
downward to the inter- 
nal malleolus, in the ten- 
don of the tibialis an- 
ticus, and about the 
same time the tension is 
felt in the inner border 
of the foot. The pa- 
tient dislikes walking 
over rough pavements; 
every stone or uneven- 
ness of the ground is 
painful to him. In this 
stage the flat foot be- 
gins to exert an influ- 
ence over the patient's 
mode of life. He walks 
less and less, uses the 

cars oftener, sits where he formerly stood, and no longer runs up or clown 
stairs or jumps off the street car; in other words, tries to spare his feet 
as much as possible. Coldness and numbness and increased perspiration 
caused by impaired circulation and weakness are common symptoms. 
There is often a severe burning sensation in the sole of the foot. In the 
advanced stage of the affection the arch is broken down; the foot is strongly 
everted, the head of the astragalus standing out as a prominent lump 
below the internal malleolus; and there is spasm of all the leg muscles, 




Fic 



20 ).- 



-Krukenberg's Pendulum Apparatus for 
Treatment of Flat Foot. 



594 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



holding the foot rigid, causing the patient to walk with that characteristic 
flat foot gait, slouchy, stiff, stumping along on his heels. The subjective 
symptoms at this stage are pain in various parts of the feet or in the calf 
muscles. The pain increases during the day, as the patients stand on 
their feet, and they feel better in the morning after the night's rest. The 
patient has difficulty in walking up and down stairs; after a period of rest 
during the day, the foot, upon using, is very stiff and painful for several 
minutes. 

Treatment. — In mild cases passive movements of the foot should be 
carried out to the full limit at morning and night, at the same time actively 
exercising the muscles by standing with the toes together and the heels far 
apart, then rising on the toes. Besides this, the patient should wear a proper 
insole to support the arch. In more severe cases, where there are dislocation 
of the astragalus and muscular spasm, it is necessary to reduce the disloca- 
tion and overcome the spasm. This may be done by forcible correction 
under an anaesthetic and the application of a plaster of Paris bandage in the 




Fig. 201. — Flat Foot. 



overcorrected position. After the plaster of Paris is dry, the patient is 
encouraged to walk about as best he can. The bandages are removed after 
from three to five weeks. Casts of the feet are taken and steel plates 
carefully modelled upon these casts. Another method is by the use of the 
Krukenberg pendulum apparatus (see illustration) . This gradually reduces 
the dislocation, relieves the spasm, and within a short time effects a com- 
plete cure, the patient actively assisting in the cure. After exercising from 
ten to fifteen minutes in the machine, the patient at once experiences great 
relief from pain and spasm and the foot will readily follow all passive 
movements. A valuable therapeutic measure is the application to the foot 
of rubber adhesive strapping. The foot is inverted as much as possible. 
Two broad strips of plaster are placed on the outer side of the leg, passed 
under the foot, and held tightly on the inner side of the leg. Narrow 
strips of plaster are now passed in a figure of eight fashion around the 
ankle. This dressing gives good support for from ten to fourteen days 
and may then be renewed. A simple but ofttimes efficacious remedy is 
the building up of the shoes } to $ of an inch on the inner side. 



FLAT FOOT OF CHILDREN 



595 



FLAT FOOT OF CHILDREN 

Children do not naturally have flat foot. On gross inspection we find 
the inner border of a child's foot touching the ground. It is apparently flat, 
and if we take an impression of the foot we find that almost all of the sole 
makes its imprint. If, however, one closely examines the foot, one will find 
in place of an arch a thick pad of tissue which gives the idea of a flat foot. 
This pad is a protection to the normal arch, which is always present. And 
when we say that the arch is formed in later childhood, we simply mean that 
this protective pad has disappeared, its function having been served, for 
now the muscles and ligaments have become firmer and the arch strong 
enough to bear the weight of the body. 

Typical cases of weak foot, however, sometimes present themselves, 
and we find them in rhachitic children or those whose muscles in other parts 
of the body are weak or where a child is growing rapidly and the muscles are 
not able to keep up with the growth. 

Flat foot is often associated with knock knee. The symptoms are pain 
in the arches and calf so that after a little exertion the child tires easily 
and cannot walk far. There is rarely muscular spasm. On examination we 
find a thin foot with the normal pad of tissue under the arch missing and 
the bony structure easily palpable. The head of the astragalus is prominent 
under the internal malleolus and on the patient's standing we find the arches 
sunken. 

The treatment for these cases is by a perfectly fitted Whitman flat foot 
plate and massage of the foot, with exercises for strengthening the muscles, 
for only in cases where a positive diagnosis of flat foot is made should any 
appliance be worn. 

The promiscuous use of corset shoes, ankle supporters, high counters, and 
elastic anklets is distinctly harmful in that they tend to further weaken the 
foot by interfering with its function, and are to be discountenanced. 



CHAPTER XXIV 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM — Concluded 

MASSAGE, SWEDISH MOVEMENTS, VIBRATORY STIMULA- 
TION, AND HOT AIR TREATMENT 

REMARKS ON MASSAGE AND SWEDISH MOVEMENTS 

The Value of Massage and Movements. — It is often an important ques- 
tion to decide whether motion or rest should be employed in the treatment 
of disease. As a general rule it may be stated that rest should be made 
use of in all acute conditions of disease when the normal activities are in 
excess, whereas motion should be employed in all chronic conditions when 
the normal activities are deficient or in abeyance. Again, there are many 
cases, both acute and chronic, in which the rest of some part could be com- 
bined with motion of other parts of the body. 

We speak of two kinds of motion, active and passive. The active motions 
comprise those which originate in the will of the patient and are executed 
without assistance. The passive comprise all movements executed and 
controlled by an alien power, independent of the will of the person operated 
upon. 

The familiar forms of massage are rubbing, kneading, tapping, rocking, 
and stroking. Vibratory massage is another valuable form of motion. 
When the patient is more or less vigorous, the simple, or active motions 
may be employed; when the patient is debilitated, the passive movements 
or a combination of both are more effective. 

Movements systematically employed may be strengthening movements, 
such as flexion, extension, torsion, etc.; or stimulating movements, as by 
percussion and vibration; or quieting movements, as by rotation and friction; 
or purgative movements, such as kneading, pressing, and active movements 
on the bowels. 

Some movements have a special effect on respiration; others on the 
circulation. Movements may be so applied as to affect any organ or portion 
of the body, increasing vital action when it is deficient and decreasing it 
when it is in excess. Movements cause an increased flow of blood to the mus- 
cles and soft parts, thereby increasing the circulation and removing accumu- 
lations of waste products. They cause absorption of exudations, transuda- 
tions and infiltrations, and often effect a separation of adhesions in tendon 
sheaths and joints. 

Movements relieve congestion of the brain, lungs, intestines, uterus, 
liver and kidneys by increasing the flow of blood to the muscles. They 
directly stimulate the sympathetic nervous system. 
596 



MASSAGE AS AN AID TO THE CIRCULATION 



597 



From the foregoing remarks it must be evident that some ailments can 
be cured more quickly by this method than by any other, but in the majority 
of cases, massage is simply a part of the general management. In some cases 
it should be resorted to only as an after-cure or as a means of exercise. 

Massage and movements are useful in disturbances of the nervous and 
circulatory systems and of the respiratory organs, in neuralgia, rheumatism, 
muscular weakness, gout, paralysis, writer's cramp, insomnia, anaemia, 
chlorosis, chronic heart disease, cold hands and feet, dyspepsia, constipa- 
tion, spinal curvature, flat chest, round shoulders, sprained ankle, stiff 
joints, fracture, etc. 

Massage Treatment of the Digestive and Pelvic Organs 

Abdominal massage is performed in many ways according to the indica- 
tions. It may be confined to the superficial structures or may be directed 
to the deep seated viscera. The principal movements for this treatment 
would be friction, kneading, and vibration. 

Friction is given by placing both hands over the abdomen, following 
the direction of the ascending colon and transverse colon on the right side 
and the descending colon on the left. Such treatment is given a number 
of times in frequent succession to patients who suffer from indigestion, 
dyspepsia, and constipation. 

Kneading is confined to the superficial structures of the abdomen. 
The operator takes hold of the flesh and lets it roll through his hands, 
starting from the middle and working toward both sides. 

Vibration massage is used with very good results in cases of chronic 
dyspepsia and catarrh of the stomach. The manipulation should never take 
place immediately after a meal. 

Generally speaking, abdominal massage promotes peristalsis of the 
stomach and intestines, facilitates the passage of food and fasces, and takes 
the place of active exercise in all cases of enforced idleness. In fact, all 
palpable viscera may have the benefit of massage and vibratory massage 
treatment. Therapeutic palpation and massage of the pelvic organs, in both 
male and female, are regularly employed and give excellent results in chronic 
congestion and indurations in which operative treatment is not called for. 

Massage as an Aid to the Circulation of Blood and Lymph 

Daily muscular contractions by means of exercise aid the circulation of 
the blood and lymph by causing a pressure on the arteries, veins, and lymph 
channels. The act of breathing also exerts a suction pump action on the 
circulation, drawing the blood toward the heart. Muscular contractions 
produce a pressure on the walls of the veins whereby the blood is forced 
toward the heart. It has been shown that effleurage stimulates the super- 
ficial muscles, produces dilatation of the superficial vessels and insensible 
perspiration, excites the skin reflexes, and, acting through the cutaneous 
nerves, increases the rapidity of the circulation and the heart beat. Massage 
forces the lymph out of the muscles, increases the velocity of the blood current 
through the part operated upon, and temporarily decreases the size of a 
limb while increasing its muscular power. 



598 OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



With the aid of massage and movements, a better distribution of the 
blood is affected. Through this the nourishment of the whole body is 
improved. The heart also will thus receive its due nourishment, and retain 
or regain its power to force the blood regularly to all parts. An irregular 




Fig. 202. — Dry Hot Air Treatment. 

action of the heart may disappear, the blood will pass more easily and with 
less obstruction through the lungs, and respiration will become deeper and 
easier. 

Treatment of Stiff Joints by Massage and Movements 

The greatest care is required in the treatment of joints, since it is quite 
possible to provoke fresh inflammatory action by rough handling. When 
massage is carried out without violence and with good judgment, it givei 
better results than any other form of treatment. The pain and discoloratior 
will in a very short time disappear, the tension diminishes as the products 
of inflammation are carried off, the fever temperature falls, the natura 
outlines reappear, extravasated blood is dispersed, and adhesions betweer 
the torn and bruised surfaces are effectually prevented. 

Treatment of Sprains by Early Massage 

It is a well known fact that massage is of the greatest value in both acut( 
and chronic cases. The earlier the patient receives treatment the soonei 
will he enjoy its good effects. Immediately following the injury the parts 
are very tender; perhaps the whole limb is swollen, the joint distended wit! 
blood and very hot to the touch. 



TREATMENT OF SPRAINS BY EARLY MASSAGE 



599 



In a case of this nature the patient should be treated by gentle effleurage 
(slight stroking) performed with the palm of the hand and of from ten to 
fifteen minutes' duration. 

As soon as the acute pain has disappeared, the masseur can apply friction 
manipulation, performed with the tips of his fingers to force away exudates. 
The masseur should begin at some distance from the affected part and work 
his way gradually to it. After a few treatments the joint becomes quite 
free and almost painless. The patient may then be allowed to use his limb, 
and if the pain does not return the exercises should be increased day by day. 
The limb should be bandaged, and a continuous hot application is service- 




Fig. 203. — Application of the Chattanooga Vibrator. 



able. Provided there is no fracture, five to ten days of treatment will bring- 
about a return to the normal condition of the parts. 

When manual treatment by massage and systematic movement are 
inadequate, we may call to our aid the various mechanical devices, such as 
the 'pendulum apparatus and the vibratile. 
39 



600 



OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 



MECHANICAL VIBRATION; VIBRATORY MASSAGE; VIBRATORY 

STIMULATION 

Mechanical vibration by means of the oscillating vibrator (see cut) is 
an important aid in the treatment of many functional and organic derange- 
ments. It increases the flow of blood and lymph to and from a given area 
or organ, thereby stimulating secretion and excretion, encouraging muscular 
and general metabolism, and relieving tissue congestion, muscular rigidity, 




Fig. 204. — Dry Hot Air Treatment for Arm or Leg. 



and pain. Like massage, it aids the general and local circulation and in- 
directly improves respiration, digestion, secretion, and excretion. 

Vibratory treatment may be applied to any accessible tissue or organ, 
and is particularly useful in chronic muscular rheumatism, in gastric and 
intestinal indigestion, in constipation, in chronic Bright's disease, in sciatica, 
in lumbago, in sprains, in neuritis and neuralgia, in chorea, in goitre, in 
insomnia, in many pelvic and joint inflammations, and in paralyses. 

Generally speaking, it has about the same indications as massage, and 
may be employed daily or every other day for fifteen to thirty minutes. 

DRY HOT AIR TREATMENT 

By means of an ovenlike apparatus hot air at a temperature of 200° to 
400° F. may be applied to almost any part of the body. This treatment 
is useful in all chronic inflammatorj^ conditions, by facilitating the transfer 
of blood and lymph. It may be used in conjunction with massage and 
vibratory massage in chronic affections of the joints, particularly in chronic 



DRY HOT AIR TREATMENT 



601 



rheumatism, witn and without plastic deposits, in gout after the acute 
stage is passed, and in all forms of neuralgia and neuritis from any cause 
whatsoever. The patient, after being undressed and wrapped in blankets, 
has his arm, leg, or any convenient portion of his anatomy placed inside a 
specially constructed cylinder which is heated to the required degree by 
gas, oil, or electricity. The exposure is continued from half to three quar- 
ters of an hour. This causes profuse perspiration and elevates the bodily 
temperature one or two degrees. 



CHAPTER XXV 



INFECTIOUS AND CONTAGIOUS FEVERS 

Synopsis: Introductory Remarks. — Prophylaxis and Disinfection. — Malarial Fevers. — 
Enteric, or Typhoid, Fevers. — Influenza. — Yellow Fever. — Typhus Fever. — Dengue. 
— Relapsing Fever. — Asiatic Cholera. — Variola. — Vaccinia and Vaccination. — 
Bubonic Plague. — (For Measles, Rubeola, Varicella, and Scarlatina, see Paediatrics. ) 

INTRODUCTORY REMARKS 

Infection is the invasion of the body by animal or by vegetable para- 
sites, bacteria, protozoa, etc. There are two principal factors in infectious 
disease, the seed and the soil. In good soil the destruction of pathogenic 
germs goes on all the time. Infective fevers are caused by specific microbes 
which disturb or destroy cellular health. In some instances the disease 
germ is known and can be handled by modern bacteriological methods. 
In many diseases the specific germ is as yet unknown. Infective diseases 
are directly or indirectly communicable in a high or low degree. A knowl- 
edge of the mode of infection and the portal of entrance of infective disease 
is of the utmost importance as regards prophylaxis. These points will be 
discussed under each separate disease; generally speaking, we know that a 
lowered state of health from any and all causes is a predisposing factor. 
In some individuals there is a natural resistance or an acquired immunity 
to infection. Certain individuals are particularly apt to contract infectious 
disease, and in almost all persons there is a liability to infection at certain 
periods and at certain ages. The new-born are liable to infection through 
the navel. In early childhood the gastroenteric and respiratory tracts 
are frequently the portals of entrance. Syphilis, gonorrhoea, and chancre 
are threatening diseases from the age of puberty up. Cancer invades the 
body more readily after middle life. Tuberculosis, influenza, pneumonia, 
malarial poisoning, and many other infectious diseases are encountered at 
any age. In some instances we find visible manifestations of the disease at 
the portal of entrance, as in diphtheria and in syphilis. In the majority 
of diseases there are no visible manifestations at the portal of entrance. 
The symptom group which is common to infective fevers consists of fever, 
a chill, sweating, a rapid pulse, loss of appetite, and various neuralgias. 
In addition we often observe special manifestations, such as skin eruptions, 
diarrhoea, etc. 

-'Fever plays an important role and is accompanied by an increased 
burning up of body tissues (muscles and fat) . Albuminuria is a phenomenon 
frequently observed in infective fevers. Secondary anaemic conditions often 
follow in the wake of infections. Heart and kidney complications with azdema, 
602 



REMARKS ON PROPHYLAXIS AND DISINFECTION 



603 



also cerebral manifestations, are not infrequent. As regards treatment, 
it may be stated that in the present state of our knowledge we have specific 
treatment only in malarial disease, syphilis, and diphtheria. The manage- 
ment of all other infections is symptomatic and general. The therapeutics 
of the future will probably deal more with substances derived from the 
animal body. Under general management we class the maintenance of 
nutrition and of the circulation, antipyretic measures, and elimination by 
the intestinal tract, by the kidneys, and by the skin. Antipyretic drugs 
are only occasionally useful. Hydrotherapeutic measures are to be pre- 
ferred to drugs for reducing the temperature. The routine practice of 
administering antipyretic drugs as soon as the temperature rises some- 
what above the normal is positively bad. Quinine as an antipyretic is 
indicated only in malarial fevers. Drug stimulants, laxatives, and hy- 
drochloric acid for the purpose of aiding digestion are the only drugs 
useful in this class of cases. 

REMARKS ON PROPHYLAXIS AND DISINFECTION 

It is not within the scope of this chapter to speak of State and inter- 
state sanitary regulations, but it may be mentioned that the enforce- 
ment of laws against river pollution and the sanitary supervision of 
inland transportation are extremely lax in our country. Quarantine and 
disinfection at our various seaports have been effectively carried out, 
and this service will doubtless continue to still further improve as soon as 
we have established a national board of health, and it would appear 
that the Marine Hospital Service has the necessary machinery for carrying 
on such work. 

The municipal control of infectious disease is satisfactory to a certain 
extent. When the efforts of our health boards fall short of the mark, it 
is well to remember that the health reformer cannot travel far beyond the 
popular standard of enlightenment in such matters. Moreover, many 
practitioners of medicine are lax and derelict in their duties as sanitarians, 
and some sanitary inspectors and officials are meddlesome and short- 
sighted. The disinfection by fumigation of sick rooms with their various 
contents, in tenement houses, is practically a farce. Much would be gained 
by prohibiting carpets and wall paper in tenement houses. The modern 
steam heated and' carpeted apartment houses with hopper closets and 
complicated plumbing on each floor, and a scarcity of sunshine and fresh 
air, are insanitary, to say the least, and in many respects inferior to the old 
style of tenements. Although the poor in our large centres of population 
may never be able to enjoy sanitary dwellings, the authorities should see 
to it that conditions are not created which are positively bad. 

The general principles involved in the prevention of infectious disease 
are not complex: 

1. Isolation of the patient and avoidance of the sick room. 

2. Disinfection of rooms and contents by steam or chemicals or by 
cleanliness and sunshine; personal disinfection and prophylaxis, including 
fortifying the system. 

3. Ventilation to prevent concentration of poisonous matter. 



604 



INFECTIOUS AND CONTAGIOUS FEVERS 



The management of a case of contagious fever in a private house accord- 
ing to these principles is not difficult. The patient is isolated in a clean 
room, bare of all but the necessary furniture. A hall bedroom or one on the 
top floor is to be preferred. In some instances it may be advisable to keep 
the patient in the ordinary bedroom occupied at the time of his being taken 
sick, and quarantine, in the best manner possible, this floor of the house, 
already infected. The well children are to be kept from school and church. 
Where the intercourse of parents with a sick child cannot be avoided, 
even when trained nurses are employed, it may become necessary to isolate 
the well children. Food and drink not consumed by the patient must be 
burned or disinfected in a slop jar holding a chlorinated soda solution. 
Dishes should be rinsed in soda solution, 5 per cent, and a sublimated 
solution, 1 to 1,000, before returning them to the kitchen. As dried sputa 
are apt to spread through the air, all expectorated matter should be re- 
ceived into rags or paper spittoons, which are to be burned, or into a jar 
holding a sublimate solution, 1 to 1,000. The sick room should not be 
swept with a broom, to avoid raising dust. For cleaning purposes, em- 
ploy moist rags, which are to be burned. Urinals, bed pans, and faeces 
are treated with quicklime, bichloride solution, 1 to 1,000, or Labarraque's 
solution. 

The nurse should not eat or drink in the same room with the patient, 
and before going to meals she should clean her hands and arms with green 
soap and sublimate solution, 1 to 1,000, and put on a clean, long, loose 
gown, which hangs outside of the sick room. During the period of desquama- 
tion the patient should receive a daily bath of tepid water containing green 
soap. At the termination of a case the nurse takes a bichloride bath, 1 to 
2,000, and washes her hair with the same solution. In case of death, the 
body is to be wrapped up at once in a bed sheet soaked in mercuric bi- 
chloride solution, 1 to 1,000, and no public funeral is to be permitted. 
The sick room and all objects in it must be disinfected (see subsequent 
rules). Hard finish or painted walls and ceilings and floors may be washed 
or sprayed with disinfecting fluids. Papered walls may be rubbed down with 
a damp cloth or bread crumbs, or, better still, the paper should be removed. 
A fresh coat of kalsomine or whitewash is advisable wherever it can be 
applied. After disinfection, the windows must be kept open day and night 
for several days. Carpets, upholstered furniture, and other articles can 
be disinfected by steam through the health board or at private disinfecting 
plants. 

Period of Isolation. — Scarlet fever patients are not to be returned to 
school until the lapse of six weeks or more. 
Measles, four weeks or more. 

Diphtheria, until cultures from the throat show that infection has dis- 
appeared. 

Varicella (chickenpox), four weeks. 
Pertussis (whooping cough), indefinitely. 

In small towns and villages with scattered dwellings the spread of con- 
tagious disease is easily prevented by isolation and rigid quarantine. The 
health officer of a town will placard the infected house and employ one or 
two persons to watch the premises and carry supplies to the inmates. From 



REMARKS ON PROPHYLAXIS AND DISINFECTION 605 



personal observation I am convinced that this supervision is lax, and sym- 
pathetic neighbors are permitted to go in and out ad libitum. Disinfection 
by steam is not feasible in small towns. Articles which are not to be 
destroyed should be disinfected by a lengthy exposure to sunlight and 
fresh air. 

In the homes of the poor in our large cities preventive measures cannot 
be thoroughly applied. The conscientious practitioner will perhaps advise 
the removal of the patient to an isolating hospital, and in the event of 
refusal will do the best he can under the circumstances. He may order 
the patient to the front or rear room having the most light and air, and 
lock the door leading to the other apartments, entrance to the sick room 
to be had by way of the hall. A tub of 3 per cent carbolic acid solution 
or Javelle water and a cake of sapolio should be placed in the sick room 
for washing hands and for soiled linen, dishes, discharges, and bed pans. 
Whenever the removal of a sick child to an isolating hospital is objected to 
by the parents, the health officers have no moral right to part mother 
and child, in the opinion of the writer. Whenever such a removal is im- 
peratively demanded, such provisions should be made that the mother 
may accompany the child. 

Prevention of Infectious Disease in Schools. — It is well known that our 
crowded schools are hotbeds for breeding infectious diseases. It is the 
experience of most families having children that all goes well until one or 
more children attend school. The writer desires to draw attention to the 
fact that most of our city churches and armories are unoccupied during 
school hours, and it would seem feasible to arrange for their utilization as 
school houses. If this suggestion should meet with favor, the difficulties 
of carrying out this plan could readily be overcome. Our municipal 
health board has made some well directed efforts to improve the hygiene 
of our schools in various ways. 

Attention has been drawn to the clothes room as a source of infection. 
Moist or damp overcoats and wraps hanging for hours in a steam heated 
room or closet are an excellent breeding ground for infectious germs. This 
is a real danger, and should merit the attention of the authorities. The 
overheating of school rooms is a perennial source of discomfort and danger, 
notwithstanding all that has been talked or written against it. An in- 
expensive automatic temperature regulator would overcome this difficulty. 
It is well known to teachers and physicians that children frequently at- 
tend school with contagious fevers, contagious sore throats, transmissible 
skin disease, ophthalmia, etc., and that they infect others during school 
hours. To avoid this, a rapid inspection of school children by qualified 
persons is necessary. This can be done before school hours, as they as- 
semble in the courtyard, and every child found sick should be sent home 
with a card bearing the inscription: " Your child is sick; consult a physi- 
cian at once." 

As soon as a case of infectious disease is reported to the health board, 
all school children from the infected house are sent home. After the ter- 
mination of the case the health inspectors should remove such restric- 
tions by at once notifying the school officers and the housekeeper of the 
infected house. 



606 



INFECTIOUS AND CONTAGIOUS FEVERS 



In New York City this is not always promptly attended to, and parents 
are compelled to adopt the roundabout way of calling on the family physician 
for a clean bill of health. Finally, it must be urged that school buildings 
be thoroughly disinfected during every vacation. Sulphur fumigations 
appear to be inadequate. Chlorine and formalin fumigations have been 
employed with success. 

The practice of compelling parents to keep children convalescent from 
diphtheria indoors and confined to the sick room until all bacilli have dis- 
appeared from the throat is unreasonable, because it deprives the con- 
valescents of the tonic effects of fresh air, which they require, and because 
the infectious nature of diphtheria bacilli found during convalescence and 
later on has not been proved. 

Professor Dunbar, the director of the Hamburg Hygienic Institute, 
recently informed the author that school children were permitted to reenter 
the schools in Hamburg very soon after the clinical symptoms of a diph- 
theritic infection had subsided, and that no notice was taken of the presence 
or absence of diphtheria bacilli in such cases, because careful investigation 
of such factors in schools and asylums had shown that the so called bacillary 
precautions had not been followed by noteworthy results. 

One of the most cruel results of the Sanitary Code as practised in some 
of our large cities is the taking away of children suffering from ordinary 
every day eruptive fevers and transferring them to a suburban department 
hospital, against the will of the parents, when such cases are reported from 
a hospital or from an apartment some portion of which is utilized for business 
purposes. 

This enactment is directed chiefly against the poor, and has given rise 
to so much bitterness of feeling that in very many instances the fear of 
the compulsory removal of a child to a department hospital has prevented 
parents from calling in a physician and has kept well meaning and humane 
physicians from reporting such cases. 

It must be conceded that in many instances it would be to the interest 
of all concerned if cases of communicable disease could be treated in a proper 
hospital; but to compel parents to give up their children in ordinary cases 
of illness is wrong. It is far better to take no stringent precautions than to 
cast discredit upon sanitation in general by enforcing cruel and unnecessary 
laws. If the community demands isolation under all circumstances, the 
authorities should insist upon securing proper accommodations for mother 
and child. 

Personal Prophylaxis. — It is positively known that a number of infectious 
and contagious diseases enter the animal economy through the nasopharynx, 
but the general practitioner does not appear to appreciate the importance 
of such observations. The writer has pointed out on various occasions 
that scarlet fever and diphtheria are very apt to attack children having 
decayed teeth, large tonsils, and adenoid vegetations. And it has been 
stated by good authority that the tubercle bacillus frequently enters the 
system through the nasopharynx, and from there travels to the bronchial 
glands and the lungs. Therefore carious teeth in children should be ex- 
tracted or filled, and large tonsils and adenoids removed. Children exposed 
to diphtheria and scarlet fever should receive a teaspoonful of salt water 



DISINFECTANTS 



607 



in each nostril several times a day. This will carry away putrescible matter 
from the nasopharynx and prevent infection. (See Nasopharyngeal Toilet.) 

Disinjcctants 

The Disinfection of Rooms. — 1. All cracks or openings in the plaster 
or in the floor or about the door and windows should be caulked tight with 
cotton or with strips of cloth. 

2. The linen, quilts, blankets, carpets, etc., should be stretched out on 
a line in order to expose as much surface to the disinfectant as possible. 




Fig. 205. — Formaldehyde Sterilizer. 



They should not be thrown into a heap. Books should be suspended by 
their covers so that the pages are all open and freely exposed. 

3. The walls and floor of the room and the articles contained in it should 
be thoroughly sprayed with water. If masses of matter or sputum are 
dried down on the floor, they should be soaked with water and loosened. 
No vessel of water should, however, be allowed to remain in the room. 

4. Five ounces of the commercial 40 per cent solution of formaldehyde 
(formalin) for each 1,000 cubic feet of space should be placed in the distilling 
apparatus and distilled as rapidly as possible. The key hole and spaces 
about the door should then be packed with cotton or cloth. 

5. The room thus treated should remain closed for at least ten hours. 
If there is much leakage of gas into the surrounding rooms, a second or 
third disinfection with formaldehyde at intervals of two or three hours 
should be made. 

In the absence of a distilling apparatus, formalin fumigation may be 
obtained by mixing one quart of 40 per cent formaldehyde and 6| ounces 
of potassium permanganate in a porcelain dish floating in a tub of water. 
The person mixing the chemicals must leave the room at once. The quan- 
tities mentioned are sufficient for a good sized room. 



608 



INFECTIOUS AND CONTAGIOUS FEVERS 



For Excreta. — In the sick room: 
For spore containing material: 

1. Chlorinated lime in solution, 4 per cent. 

2. Mercuric chloride in solution, 1 to 500. 
In the absence of spores: 

3. Carbolic acid in solution, 5 per cent. 

4. Sulphate of copper in solution, 5 per cent. 

5. Chloride of zinc in solution, 10 per cent. 
In privy vaults: 

Mercuric chloride in solution, 1 to 500. 

For the disinfection and deodorization of the surface of masses of organic 
material in privy vaults, etc. : 
Chlorinated lime in powder. 

For Clothing, Bedding, etc.— Soiled underclothing, bed linen, etc.: 

1. Destruction by fire, if of little value. 

2. Boiling for at least half an hour. 

3. Immersion in a solution of mercuric chloride of the strength of 1 to 
2,000 for four hours. 

4. Immersion in a 2 per cent solution of carbolic acid for four hours. 
Outer garments of wool or silk, and similar articles, which would be 

injured by immersion in boiling water or in a disinfecting solution: 

1. Exposure to dry heat at a temperature of 110° C. (230° F.) for two 
hours. 

2. Fumigation with sulphurous acid gas for at least twelve hours, the 
clothing being freely exposed and the gas present in the disinfection chamber 
in the proportion of four volumes per cent. 

Mattresses and blankets soiled by the discharges of the sick: 

1. Destruction by fire. 

2. Exposure to superheated steam — 25 pounds pressure — for one hour. 
(Mattresses to have the cover removed or freely opened.) 

3. Immersion in boiling water for one hour. » 

4. Immersion in the blue solution (mercuric chloride and sulphate of 
copper), two fluid ounces to the gallon of water. 

For Furniture and Articles of Wood, Leather, and Porcelain. — Washing, 
several times repeated, with: 

1. Solution of mercuric chloride, 1 to 1,000. (The blue solution, four 
ounces to the gallon of water, may be used.) 

2. Solution of chlorinated lime, 1 per cent. 

3. Solution of carbolic acid, 2 per cent. 

For the Person. — The hands and general surface of the body of attendants, 
of the sick, and of convalescents at the time of their discharge from hospital. 

1. Solution of chlorinated soda diluted with nine parts of water (1 to 10). 

2. Carbolic acid, 2 per cent solution. 

3. Mercuric chloride, 1 to 1,000; recommended only for the hands, or 
for washing away infectious material from a limited area, not as a bath for 
the entire surface of the body. 

For the Dead. — Envelop the body in a sheet thoroughly saturated with: 

1. Chlorinated lime in solution, 4 per cent. 

2. Mercuric chloride in solution, 1 to 500. 



MALARIAL OR INTERMITTENT FEVERS 



609 



3. Carbolic acid in solution, 5 per cent. 

To Prevent the Spread of Specific Vulvovaginitis the Following Rules 
are to be Observed. — All vessels are to be sterilized immediately after use. 
Chamber marked clean is to be used for clean cases only. 
Chamber marked vaginitis is to be used for vaginitis cases only. 
Douche pans ditto. 

All wash cloths are to be sterilized after use. 

The night blankets of any child with vaginitis are to be kept on the bed 
and not used for any other child. 

All diapers worn by girls are to be first cleansed and then sterilized for 
twenty minutes. 

To Prevent the Spread of Diarrhceal Disorders. — A nurse must thor- 
oughly cleanse her hands with green soap before feeding the child suffering 
from diarrhoea. All soiled diapers are to be put in a 2 per cent solution of 
crude carbolic acid as soon as they are removed from the child. 



INFECTIOUS AND CONTAGIOUS FEVERS 

MALARIAL OR INTERMITTENT FEVERS 

etiology. — A specific infectious disease with intermittent or remittent 
fever due to the presence in the blood of several species of hamosporidia 
which develop in the blood at the expense of the red blood cells. 

Geographical Distribution. — Malarial fevers occur in almost all parts of 
the world except in the coldest regions, and are most prevalent in moist 
tropical regions. The pernicious forms are seen in tropical Africa, India, 
and South America. Intermittent fevers are limited to swampy areas, 
along river valleys, at the foot of mountains, and on coast districts, or 
wherever there is stagnant water and at the same time wherever there are 
the Anopheles mosquitoes. 

Parasitology of Malarial Fevers. — Certain varieties of mosquito (Anoph- 
eles), whose geographical distribution is as yet imperfectly known, are 
the intermediate hosts of the malarial fever parasite, which undergoes a 
cycle of existence in the insect lasting for about ten days. At the end of 
this period sporoids may be introduced into the human body with the bite. 
Mosquitoes are, as far as known, the only means of conveying malaria. 

The infectious agents belong to the class of Sporozoa and to the order 
named Hamosporidia, and were discovered in 1880 by a French army 
surgeon, Laveran. Three distinct species have been distinguished: 

The tertian fever parasite, the quartan fever parasite, and the cestivo- 
autumnal fever parasite. Malaria is so widely disseminated over the world 
and the opportunity for continued infection of the mosquito so great that 
it seems almost hopeless to try to eradicate the disease. The principle 
upon which malaria may be fought has been suggested by science and has 
proved of value. This involves the destruction of the mosquito and its 
breeding places, the prevention of the infection of the remaining mos- 
quitoes by isolation of the malarious individual from the mosquito, and the 
diminution of malarial material in man by an attempt to cure him with 
quinine and other antimalarial remedies. 



610 



INFECTIOUS AND CONTAGIOUS FEVERS 



Experiment has already demonstrated that non-immune individuals 
may live safely in the most malarious districts with adequate yet simple 
protection from the sting of the mosquito infected with malaria. Man 
thus protected against malaria may now explore, settle in, and develop 
regions of the earth hitherto inaccessible because of the danger from the 
deadly tropical malaria. 

Prophylaxis of Malaria. — The health board of New York has issued 
the following lucid instructions regarding the prevention of malaria which 
embody our present knowledge of the subject. 

This disease, which is also called "ague," "chills," "chills and fever," 
and "dumb ague," has been thought due to stagnant water, to upturned 
soil, to bad air, and to other causes. It has now been proved beyond doubt 
that it originates from the bite of a certain kind of mosquito (Anopheles) 
and as a rule in no other way. This mosquito is not created with malaria, 
but gets the germs into its stomach by biting a person already infected. 
After the lapse of about eight days, such a mosquito becomes capable of 
infecting other persons, previously healthy, by its bite, thus passing the 
disease on indefinitely. 

To prevent malarial disease, therefore, we must either destroy the dan- 
gerous mosquitoes or avoid their bites. In practice, both expedients are 
desirable. As the malarial mosquitoes bite as a rule only at night, one 
will usually be safe by protecting the bedroom, either with screens at the 
windows or with a mosquito bar carefully arranged over the bed. Before 
going to bed one should kill all the mosquitoes resting on the bedroom walls, 
in the closets, or under articles of furniture, as the insects already in the 
room are most apt to give trouble. Moreover, all cases of malarial disease 
already developed must be carefully isolated under mosquito netting until 
pronounced by a competent physician to be cured. Otherwise, malarial 
mosquitoes biting these persons, and flying out of doors again, may carry the 
infection some distance in all directions. Various epidemics in our suburbs, 
in past summers, have been thus begun. 

The other and still more important measure is to prevent the breeding of 
mosquitoes in one's neighborhood. All mosquitoes, the malarial as well as 
the common household pests which only annoy us, require standing water to 
lay their eggs in. Mosquitoes will lay in water barrels, pans, tin cans, wells, 
springs, rain pools, cesspools, pots, kettles, drainage traps, ponds — in short, 
anywhere where stagnant water is found. Running streams are not apt to 
support the young, unless the current is sluggish. Large bodies of water 
are usually kept clear by the small fish in the water — minnows, small 
sticklebacks, sunfish — except when the margins of the water are cumbered 
with grass, slime, or leaves, preventing the fish from getting at the mosquito 
larvae, which are very expert at hiding. Mosquitoes, as a rule, cannot live 
in salt water. To kill the mosquito larva?, therefore, the rule is simple: 
no standing water. Where standing water must be had for washing or drink- 
ing, the top of the receptacle should be closely covered with wire gauze — 
not the smallest opening being left at the margin. When drainage cannot 
be made possible, the surface of the water should be covered with a film 
of kerosene oil. The oil may be poured on from a can or sprinkler. It will 
spread of itself. One ounce of oil to fifteen square feet of water is enough. 



MALARIAL OR INTERMITTENT FEVERS 



611 



The oil must be renewed about once a week during the mosquito season. 
A solution containing 1 pound of sulphate of copper and 1 pound of unslaked 
lime in 10 gallons of water will cause the death of mosquito larva? when 
added in the proportions of one gallon of solution to 50 gallons of infected 
water. 

Mosquitoes do not fly far from their breeding places, and if all the 
householders in a given neighborhood will observe the simple rules given, 
experience has already amply proved that the results will be amazing. 
Persons keeping stagnant water on their premises are guilty of maintaining 
a nuisance, and it is the purpose of the department to proceed against all 
who neglect the warning of the department in this respect. Where large 
bodies of water, the drainage of which is too expensive for private enter- 
prise, are in question, the department hopes to enlist the assistance of the 
proper city authorities, so that there need be no reason why the plague 
of mosquitoes and malaria in the suburbs of New York should not be 
entirely removed. 

The Infection in Young Children. — A most important fact which was 
independently observed by Koch in Africa, is that in a native population 
in a malarious region, while the adults may be perfectly free from the disease, 
an enormously large percentage of the young children contain the parasites 
in their blood. Though the disease appears to be much less dangerous to 
the native children than to the newly arrived, implying that they have a 
degree of congenital immunity, the parasites in the young natives are per- 
fectly efficacious in causing dangerous fever in white people, when conveyed 
to them by mosquitoes. Hence the important practical inference that 
white people settling in a malarious tropical region should not, as they now 
commonly do, plant their houses near native settlements, but place them 
at some considerable distance from them, about a quarter of a mile being 
apparently sufficient. Christophers and Stephens in their last communica- 
tion have gone so far as to express the opinion that the following of this 
simple rule would go very far indeed toward rendering the malarious tropics 
healthy for Europeans. 

The routine administration of quinine to the malaria bearing native 
population in order to avoid the infection of new broods of mosquitoes is, in 
most regions, beyond possibility. But a combination of these methods and 
the general use of mosquito netting is bound to yield good results. Sooner 
or later we shall find some plant that will prevent the breeding of mosqui- 
toes or some innocuous gnat which will displace the dangerous Anopheles. 

Symptoms. — The symptoms differ according to the species with which 
the individual is infected. A paroxysm of fever has four stages: Pre- 
monitory symptoms, chills, fever, and sweating. 

The premonitory symptoms are headache, languor, nausea and vomiting, 
yawning, and a feeling of cold. 

The Chill. — The patient shivers and shakes, the skin is cool, pale, or cya- 
notic, the pulse is rapid, small, and hard, and the temperature rises rapidly. 

The Hot Stage. — The skin becomes hot and flushed, the eyes are injected, 
there is headache, sometimes with active delirium, the pulse is full and 
bounding, the temperature reaches its maximum — 105°, 106°, or 108°, and 
the fever drops in from six to eight hours by crisis. 



612 



INFECTIOUS AND CONTAGIOUS FEVERS 



The Stage of Sweating. — Sweating sets in as the temperature falls, and 
all the other symptoms rapidly disappear. The duration of the paroxysm 
is from eight to twelve hours, and the paroxysm returns with free intervals 
of one or more days. Herpes labialis is a common occurrence in malarial 
fever. 

Course and Termination. — After the disease has lasted for about two 
weeks the patient may get well without any special medication. A per- 
sistence of the fever leads to anaemia, to jaundice, and ultimately to chronic 
cachexia. 

Diagnosis. — The diagnosis is established by means of a blood examina- 
tion, also by the therapeutic test, i. e., the administration of repeated full 
doses of a quinine salt (gr. 5 to 15). That an intermittent fever is not 
malarial may be affirmed with almost absolute certainty if it does not 
cease after applying the therapeutic test for several days. 

Differential Diagnosis. — It is clinically important to know that various 
diseased conditions are accompanied by intermittent pyrexia. 

In pycemia or concealed suppuration, the chills, fever, and sweats occur 
at irregular intervals, the plasmodium is absent, and quinine has no influence. 

In tuberculosis the therapeutic and blood tests are negative and tubercle 
bacilli are present in the sputum in pulmonary cases. Incipient tuberculosis 
and chronic malaria are difficult to distinguish one from another. 

Pyelitis may closely simulate intermittent fever. We find in such cases 
pyuria, leucocytosis, a tender and swollen kidney, and no response to the 
therapeutic or blood test. Pyelitis may, however, be due to malarial 
infection. 

Ulcerative endocarditis with an intermittent fever curve is recognized by 
the history, the clinical symptoms and physical signs, and failure to respond 
to the blood or therapeutic test. Ulcerative endocarditis with and without 
choreic movements may follow in the wake of malarial infection in children 
and adults. 

In gallstone colic with chill and intermittent pyrexia the blood and 
therapeutic tests show negative results. 

Typhoid Fever. — Remittent malarial fever may simulate typhoid fever 
very closely. In the absence of both the Widal reaction and the plasmodium 
test, a fever of over a week's duration which resists the action of quinine is 
usually typhoid fever. 

To distinguish pernicious malarial fever with jaundice from yellow fever 
we rely upon the blood test. 

Clinical Varieties. — Intermittent malarial fevers (quotidian, tertian, 
quartan); remittent malarial fevers; pernicious malarial fever (algid, coma- 
tose, and haemorrhagic forms); malarial cachexia; dumb ague, or larvate 
malaria, the masked, irregular type. 

Symptoms of Malarial Fevers. — The symptoms of malarial fevers differ 
according to the species of parasite with which the individual is infected. 

Quartan Type. — The paroxysm, which may last from eight to twelve 
hours, consists of three stages, chill, fever, and sweating, occurring regularly 
every fourth day, with headache and pain in the back, nausea, vomiting, 
and diarrhoea. Irregular or continued fever as a result of the infection 
with multiple groups of parasites may also be present. 



MALARIAL OR INTERMITTENT FEVERS 



613 



Tertian Type. — The paroxysm occurs every other day. Infection with 
two groups of tertian parasites results in daily paroxysms. 

The .estivoautumnal type, or remittent malarial fever, is a more 
severe type which occurs in temperate regions only at the height of the 
malarial season. The fever is irregularly intermittent, remittent, or con- 
tinuous. Frequently the chills are absent and the fever resembles that of 
typhoid fever. 

Pernicious Fever. — The malarial paroxysms may assume a malignant 
and fatal form with all the characteristics of an intense infection, including 
the comatose state. This type, like the remittent fever, is due to the 
aostivoautumnal parasite and is rare in temperate zones. In the algid 
form the onset is sudden with vomiting, watery diarrhoea, and collapse. 
Sometimes there is anuria, and the patient may die from exhaustion with 




a subnormal temperature. The comatose form is accompanied by high fever 
and active delirium. Recurrent attacks are often fatal. In the hemor- 
rhagic forms an acute hemorrhagic diathesis develops with subcutaneous 
ecchymoses and haemorrhages from any surface, and with all the symptoms 
of toxaemia, such as jaundice, heematuria, haemoglobinuria, albuminuria, 
anuria, and uraemia, and not infrequently death results. 

Malarial Paroxysms with Long Intervals. — The intervals may be- 
five or six days or even weeks, may occur in all three types of infection, 
and are due to the fact that many parasites are destroyed at the time of 
sporulation and a new incubation period must be passed through before the 
number is sufficient to cause renewed symptoms. In all forms of malarial 
fever the spleen is generally enlarged. 

Malarial Fever Cachexia. — The general symptoms are those of splenic 
anaemia with breathlessness on exertion and oedema of the ankles. The 
spleen is large and hard and the liver is often enlarged. The skin has a 



614 



INFECTIOUS AND CONTAGIOUS FEVERS 



dirty yellow color and is sallow. The temperature may be normal or it 
may vary from 99° to 103°. The. red blood cells may sink in numbers to 
one million. Retinal and other haemorrhages may occur. 

Latency and relapse in intermittent fevers are clinical expressions of 
numerical fluctuations which occur in the successive broods of parasites 
in connection with conditions more or less favorable to their multiplication 
in the blood. During latency the slightest change in the condition of the 
host, such as exposure to cold, fatigue, and intercurrent disease, may give 
rise to a relapse. 

The masked irregular types are a subacute form of malarial fever 
with malaise and various neuralgias, and they are oftener seen in children 
than in adults. (See Pediatrics.) 

Complications of Malarial Fever. — In about 10 per cent of cases we 
observe complications in malarial fever, involving the gastroenteric, respira- 
tory, circulatory, urinary, and central nervous systems and the organs of 
locomotion, particularly shown by jaundice, cardialgia, and enteralgia, 
pain in the muscles and joints, wry neck, tendovaginitis crepitans, nephritis, 
and bronchopneumonia. Trophic disturbances, such as redness of the eye- 
lids and corneal ulcers, have been observed by the author. Paraplegia 
is reported as a rare complication. Bronchopneumonia is a common com- 
plication in children. Endocarditis, acute and chronic, has followed in the 
wake of malarial infection. 

Malaria as a complicating factor in other diseases may give rise 
to a development of misleading and grave symptoms, particularly in ab- 
dominal affections. Mild attacks of gallstone, renal, and appendicular 
colic or indistinct ileocsecal symptoms, with subsequent fever and chills 
due to a complicating malaria, are not at all of rare occurrence, and give 
rise to serious errors in diagnosis and treatment. The same is true of post- 
operative fever and chills; therefore the careful clinician will apply the blood 
test or therapeutic test before advising an operation or a repetition of an 
operation already performed. 

For malaria in children, see Paediatrics. 

Prognosis. — In intermittent malarial fever the prognosis is favorable 
with proper treatment, and in remittent malarial fever it is usually favor- 
able, although death may occur in severe cases. In pernicious malarial 
fever the mortality ranges from 20 to 25 per cent. In malarial cachexia 
the outlook is fairly good. The spleen gradually becomes reduced in size, 
but it may take years before the ague cake entirely disappears. When 
the heart valves or kidney tissue are damaged, the prognosis is tempered 
in accordance with such and other possible complications. The mortality 
of malaria in malarious districts with a considerable population is large. 
Thus, Professor Celli says that the mean mortality from malaria in Italy 
is about 15,000 victims annually, and that about 2,000,000 cases occur in 
Italy each year. As the mean duration of malaria is generally long, some- 
times infecting the individual for years, the loss of labor and of production 
and the expense entailed in dealing with the disease amount to several 
millions of francs. Furthermore, Celli says that, owing to malaria, about 
5,000,000 acres of land remain uncultivated, with a resulting large economic 
loss. According to the very accurate calculations of Ricchi, the Adriatic 



TREATMENT OF MALARIAL OR INTERMITTENT FEVERS 



615 



Railway Company, with 1,400 kilometres of road and employing 6,416 men, 
spends on account of malaria alone 1,050,000 francs a year. In the Italian 
army, in the twenty years from 1877 to 1897, there occurred more than 
300,000 cases of malarial disease. Finally, Celli says malaria annually 
costs Italy very large sums. 

Treatment. — Quinine is a specific for malaria without any preparatory 
treatment. Ten grains twice a day may be given for three or four days, 
then ten grains once a day for three or four days, then five grains once a 
day for a week. It matters little when the quinine is given. It should 
be given in solution or in a wafer or compressed tablet, not in a gelatin 
capsule, which often passes unchanged through the intestines. It may be 
given in suspension with the compound elixir of taraxacum or fluid extract 
of licorice. Quinine may be given hypodermically by using the soluble 
salt, quinine and urea hydrochloride, in 5, 10, or 15 grain doses. The 
oleate of quinine and quinine suppositories are practically useless. The 
tannate of quinine lozenges are too weak to be of value as an antiperiodic. 
Certain precautions must be observed in the hypodermic use of quinine and 
urea hydrochloride, to avoid cellulitis, slough, or abscess. The solution is 
to be thrown deep into the subcutaneous tissue, no drop is to be allowed 
to fall on the skin in withdrawal of the needle, and the point of puncture 
is to be sealed with tincture of iodine or iodoform collodion. 

Euquinine is not so bitter as the ordinary quinine salts, and is more 
readily swallowed by children and not so readily vomited. It is given in 
the same doses as the sulphate. "Sweet quinine" (saccharinate of quinine) 
has been recently introduced. It is of full strength (about the same strength 
as the sulphate) and is obtainable as a granulated powder or in the shape 
of compressed tablets. It is sweet to the taste. The author has used it in 
his hospital and private practice with uniform success. 

When the paroxysms have subsided, the following combination is ser- 
viceable to prevent relapses: 



R Quininae sulph., ) 

Acid, sulphur, arom., V aa, 5j; 

Solut. arsenical. Fowl., ) 

Syr. c. aurant., . §j ; 

Aquae, ad, Bvj. 



M. S.: A tablespoonful twice a day after eating. 

Or, 

R Warburg's tincture with aloes, \ oz. every morning 



after breakfast. 

Or, 

R Quininse sulph., 5j; 

Elix. taraxaci comp., oij- 

M.S.: A teaspoonful twice a day after eating. 

Or, 

R "Sweet quinine," gr. v; 

Acid, arsenios., gr. 

M. S. : Take two powders a day. 
40 



616 



INFECTIOUS AND CONTAGIOUS FEVERS 



Opium and chloral may be indicated to control nervousness, and 
stimulants, such as alcohol and strychnine, may be necessary. In the 
comatose form enteroclysis and cooling sponge baths and douches are to 
be used. 

Inhalations of hydrofluoric acid have been used in chronic malarial 
disease and in cases in which a patient did not tolerate quinine at all, by 
Olivieri, an Italian physician (Nouveaux remedes, October 8, 1902). Methyl- 
ene blue, in \ to 4 grain doses three times daily, has been successfully given 
in cases in which there was an idiosyncrasy to quinine. The administration 
of this drug is often followed by strangury, nausea, vomiting, and headache. 
Powdered nutmeg lessens the tendency to strangury. The urine turns 
an indigo blue. It may be valuable in haematuric and haemoglobinuric 
fevers. Tincture of iodine, given internally in one to two drop doses, is 
recommended in cases of quinine idiosyncrasy. In protracted convalescence 
and in chronic malaria a change of air from seashore to mountain, baths, 
general massage, and active exercise are called for. 

The treatment of the various sequelae and complications of malarial 
disease presents no special points and will be found under separate headings. 

ENTERIC FEVERS (TYPHOID AND PARA-TYPHOID FEVERS) 

Definition. — Typhoid fever is an acute infectious disease due to the 
invasion of the Bacillus typhosus of Eberth, causing inflammation and 
ulceration of the lymph follicles of the intestine and swelling of the mesen- 
teric lymph nodes and the spleen. 

The chief symptoms presented during an attack are protracted fever, 
diarrhoea, tympanites, wasting, headache, insomnia, delirium, anorexia, 
prostration, and mental apathy. The disease is self-limited, and death 
occurs from asthenia, visceral complications, haemorrhage, or perforation, 
followed by peritonitis. 

The specific germ is not the only pathogenic factor, as it has been proved 
that in the latter stages of the disease other microorganisms play an impor- 
tant part, not only in determining the extent and character of the bowel 
lesions, but also in the production of general toxic infection. 

Clinically, the disease is marked by fever and wasting, roseola, diarrhoea, 
abdominal tenderness, and tympanites, such symptoms being inconstant, 
however. The remote effects are inflammatory and degenerative changes 
in various organs and tissues. Enteric fever is common in early and middle 
life; it has a period of incubation of from eight to twenty-three days, 
during which time there is a feeling of weakness and lassitude. Family 
predisposition has been noticed; a second infection is rare. In the early 
stage of enteric fever the bacilli are found in the lymphoid tissue of the 
intestines, and afterward in the spleen, liver, kidneys, bone marrow, bile, 
and urine. 

Modes of Infection. — ^Etiology. — Enteric fever and Asiatic cholera are 
caused by swallowing food and drink contaminated by the discharges of 
previous cases. Milk contaminated with enteric fever water may carry the 
infection, also raw oysters taken from contaminated water. The Bacillus 
typhosus is not destroyed by freezing, and may be conveyed by means of 



ENTERIC FEVERS (TYPHOID AND PARA-TYPHOID FEVERS) 617 



ice. Uncooked vegetables may carry the infection, and in all probability 
the common house fly is occasionally the vehicle of its transmission. 

Prevention op the Spread of Enteric Fever. — In order to reduce 
the danger of infection to a minimum we must secure pure water and good 
drainage; isolation of the sick; and disinfection of urine, faeces, and their 
receptacles, soiled linen, soiled hands of the nurse or attendant, and 
soiled thermometers. 

Drinking water is the chief source of infection. One single case may 
prove the starting point of an epidemic. Enteric fever germs live a long 
time in water and soil. The influence of abolition of urban wells and the 




Fig. 207. — Typhoid Fever in Berlin Before and After Sand Filtration of Drinking 

Water (Seibert). 



introduction of sand filtration of drinking water on the mortality from 
enteric fever is graphically shown by the accompanying chart, taken from 
the New York Medical Journal, November 29, 1902. 

"On passing to the influence of sand filtration of drinking water on 
typhoid mortality, we again find in the experience of Berlin the most con- 
spicuous example, for instead of one typhoid death in every 900 inhabi- 
tants annually from 1843 to 1853, this city lost but one person out of every 
9,000 of typhoid annually from 1883 to 1893, although not all of the city's 
wells had been closed and the supply of filtered water from the old water- 
works (installed in 1853) had become insufficient on account of the rapid 
growth of the city. But when, about 1892, the new waterworks which 
could supply 2,500,000 inhabitants with pure, filtered water, were com- 



618 



INFECTIOUS AND CONTAGIOUS FEVERS 



pleted, this mortality was promptly reduced to one in 50,000, although 
the population of Berlin had increased from 400,000 in 1853 to 2,000,000 
in 1890." (Seibert.) 

If the typhoid germ is transmitted to persons in close connection with 
the patient, only isolated cases occur (infection by contact). The prepara- 
tion, storage, and sale of provisions in or near rooms occupied by typhoid 
patients should not be allowed, and typhoid patients should be trans- 
ported in ambulances which can readily be disinfected. If the germs are 
transmitted to articles in general use, such as milk and water, epidemics 
may arise. 

Typhoid Fever from Rural Districts. — "The ordinary farmer, with the 
'moss covered bucket' and clear well water, is not always to be trusted 
as an expert sanitarian, nor is he apt to volunteer any information concern- 
ing the fever cases that have occurred either in his own house or in that of 
his neighbor. 

" An old well is always a menace, and when it becomes poisoned it is 
next to impossible to make it safe afterward. Even brooks take a long 
while to cleanse themselves, and the microorganism has been known to 
exist over eighty days at a time in filter sand. 

" Defective surface drainage quite naturally prolongs the period of 
chance infection. Contaminated manure is also a factor, and salads and 
other garden produce are likely to be the vehicles for the conveyance of 
the germ directly to the consumer." 

Under all circumstances a rigid and frequent inspection of dairies and 
the households of dairymen is a necessity, and wells which have been con- 
taminated by enteric fever discharges should be closed up. As regards 
personal prophylaxis, it may be stated that the individual can best protect 
himself in an infected district by drinking water and milk which have been 
boiled and by remembering that raw oysters may carry the infection and 
that air-borne contagion is a possibility, inasmuch as germs may be diffused 
in the dust of dried excreta and light on milk, meat, and vegetables, and 
that it may be carried by flies which have found access to the excrement 
of typhoid fever patients. Persons travelling by railroad or boat should not 
drink unboiled water or milk unless they are sure of its purity. 

The importance of the disinfection of the urine, fseces, sputum, and bed 
linen cannot be overestimated, for it strikes at the root of the evil. Persons 
afflicted with typhoid fever should never use closets. All excretions (from 
bowels, bladder, or stomach) should be retained in easily cleansed vessels 
and never thrown into closets or manure heaps before being disinfected. 
They should be rendered innocuous by means of lime milk or chlorinated 
lime or diluted carbolic acid before being removed. In cases of emergency, 
if no disinfectants are at hand, the excrements can be buried in places far 
removed from drains, pumps, and buildings, where infection is not to be 
feared. Special care must be taken not to carelessly throw excrements 
away or soil the floor, clothes, etc.. not even with traces of the excrements. 

Special attention must be given to the sputum of patients in order to 
render it innocuous. Handkerchiefs and cloths which were used must be 
placed for at least one hour in diluted cresol or boiled in water before 
being sent to the laundry. 



ENTERIC FEVERS (TYPHOID AND PARA-TYPHOID FEVERS) 619 



For catching the sputum and wiping the mouth and nose, it is best to 
use gauze cotton rags, which must be disinfected after use or burned. 

The evacuations and urine of typhoid patients should never be thrown 
near pumps or drains, where water for drinking and other purposes is taken; 
the vessels after being emptied should never be cleansed at places from 
which water is supplied or taken. Water used for washing and bathing 
typhoid patients can also cause infection. It must therefore be rendered 
innocuous and must not be poured away near drains and pumps. If 
possible, it should be made innocuous by an addition of chlorinated lime 
before removal, in order to prevent all infection. 

Attention must be paid to the fact that the evacuations of persons who 
have had typhoid fever, and who are already convalescent, yet contain 
infectious germs for a long period. Such persons must be treated as if 
they were still ill, as far as disinfection is concerned, until the physician 
declares that infection is no longer to be feared. 

Treatment of Body and Bed Linen, Clothes, and Other Articles of Use. — 
All washable clothing, such as body and bed linen and washable parts of 
clothing, should remain at least one hour in diluted solution of cresol or 
boiled in water before being sent to the laundry. Articles of clothing used 
by typhoid patients, which cannot be washed, should be disinfected with 
steam in a disinfecting establishment if possible. If this is not possible, 
they should be well brushed with diluted water of cresol. All eating utensils 
(plates, cups, glasses, spoons, forks, knives, etc.) used by typhoid patients 
should be thoroughly cleansed with hot soda solution before being used by 
other persons. 

The Symptoms of Enteric Fever. — The prodromal symptoms, extending 
over a week or ten days, are loss of appetite, nausea, vague pains, faint 
rigors, and diarrhoea or constipation. There is a steady rise of temperature, 
and toward the end of the first week a rash appears on the abdomen, chest, 
back, or extremities, which is rose-colored, not elevated, and disappears 
on pressure (roseola). The spleen may or may not be enlarged. 

In the second week the fever becomes higher and the pulse more rapid 
(110). The mouth, throat, and lips are dry, the tongue has a brown coating, 
and the face has a dull expression. Ueocaecal gurgling, tympanites, 
diarrhoea, and abdominal tenderness are present in pronounced cases, and 
sympto'ms of disorder in the nervous and respiratory system are noticeable. 

In the third week the temperature and pulse are quite high (pulse 120 
to 130), with a morning remission and a tendency to decline. The abdominal 
symptoms are pronounced, and haemorrhage or perforation of the bowel is 
not infrequent. 

About the end of the third week or beginning of the fourth week con- 
valescence usually sets in, but severe cases often drag on to the fifth, sixth, 
and even the twelfth week. The fall of temperature is gradual; the evening 
temperatures are 1° to 2° higher than the morning temperatures. In rare 
instances the fever type is inverted, the high temperature being noted in 
the morning. 

The Fever of Convalescence. — After the temperature has been 
normal for several days there may be a sudden rise to 102° or 103°, with a 
drop to the normal within a day or two. This is generally due to constipa- 



ENTERIC FEVERS (TYPHOID AND PARA-TYPHOID FEVERS) 621 



tion or indigestion and necessitates a careful clinical inquiry as to possible 
complications. 

The fever op relapse is similar to that of the original attack, though 
generally but not always milder, and may persist for weeks. 

Respiratory symptoms in enteric fever are rapid breathing, bronchial 
moist rales, and other signs of acute bronchitis. 

Circulatory Symptoms. — In the beginning the pulse is usually dicrotic. 
When the heart sounds become feeble, a soft systolic murmur may be heard 
over the heart. 

Gastric Symptoms. — A coated tongue with red edges and loss of 
appetite are generally observed. Sordes collect upon the teeth. Nausea 
and vomiting are not frequent. 

Intestinal Symptoms. — Abdominal tenderness, tympanites, and ileo- 
cecal gurgling are usually present. Whether diarrhoea or constipation is 
present depends upon the situation of the intestinal lesion. The pea soup 
stools are characteristic. 

Nervous Symptoms. — Headache, mental torpor, muttering or active 
delirium, subsultus tendinum, stupor, and coma may be present. 

Other Symptoms. — The blood shows a reduction of the haemoglobin 
index, a lowering of the number of red corpuscles, and no leucocytosis. 

The urine is high colored and often there is retention. Ehrlich's diazo 
reaction is frequently observed. The urine may contain albumin, tube 
casts, blood, and great quantities of typhoid bacilli. 

The skin may be hot and flushed or moist, pale, and slightly cyanotic 
in circulatory failure. Roseola, erythema, and sudamina are generally to 
be seen. 

The eyes are often injected and the pupils are generally dilated. Hearing 
is usually dull. 

Diagnosis of Enteric Fever. — The diagnosis is based on the clinical 
symptoms, the peculiar temperature curve, the presence of rose spots, the 
positive Widal reaction, the absence of leucocytosis, the positive diazo 
reaction, and the failure of the blood test and therapeutic test for mala- 
rial infection. In a certain number of cases the Widal test remains nega- 
tive, and all the clinical evidences of enteric fever are present. Such 
cases are explained on the assumption of a paratyphoid fever, due to 
bacillary infection not of the Eberth bacillus variety. 

Differential Diagnosis. — Diseases Simulated by Enteric Fever. — A 
localization of the enteric fever poison in the meninges may simulate cerebro- 
spinal meningitis; a localization in the kidneys gives symptoms of acute 
nephritis; a localization in the lungs may simulate acute lobar pneumonia. 
A positive Widal reaction and the presence of other clinical manifestations 
of enteric fever will set us right. The distinction of malarial remittent and 
enteric fever rests upon the following points: In remittent malarial fever 
we often find herpes labialis, the pulse is rarely dicrotic, there are no rose 
spots, and the abdominal symptoms are not marked. In about seven 
days after the onset of the disease the plasmodia should be abundant in 
the blood and the administration of quinine will influence the fever, while 
the Widal reaction will be wanting. A double infection of enteric fever and 
Plasmodium fever is theoretically spoken of as typhomalarial fever. 



622 



INFECTIOUS AND CONTAGIOUS FEVERS 



Sim-pie Continued Fever. — A fever of gastric or intestinal origin may 
last for seven or eight days and simulate enteric fever. The blood and 
urine reactions, the therapeutic quinine reaction, the clinical symptoms, and 
the roseola of enteric fever are absent. 

The cestivoautumnal variety of malarial fever may simulate enteric fever. 

Acute miliary tuberculosis will show an irregular fever and a more rapid 
respiration and pulse. The therapeutic and blood tests will be negative. 
The diazo reaction is occasionally observed in tuberculosis. Tubercle 
bacilli may be found in the sputum. 

Tuberculous peritonitis, salpingitis, and catarrhal enteritis may be mis- 
taken for enteric fever. The Widal test should be applied, and a local 
examination and the absence of clinical symptoms of enteric fever will lead 
us to a correct diagnosis. 

Appendicitis may simulate enteric fever, the latter may simulate ap- 
pendicitis, and appendicitis may complicate enteric fever. The abrupt 
onset, a careful local examination, and the absence of. the Widal reaction 
will establish the correct diagnosis. 

In subacute ulcerative endocarditis, which may be mistaken for enteric 
fever, we observe recurrent chills, an irregular fever type, and endocardial 
murmurs, whereas rose spots, abdominal symptoms, and the Widal reaction 
are absent. 

Influenza is rarely mistaken for enteric fever. The absence of the Widal 
reaction and the finding of the influenza bacillus in the sputum will lead to 
the correct diagnosis. 

Uraemia of a subacute or chronic type, with slight rise of temperature, 
stupor, and a rapid pulse, may be mistaken for enteric fever. In the absence 
of a rose rash and the Widal reaction, and with positive urinary findings, 
the distinction should not be difficult. 

Trichiniasis has been diagnosticated as enteric fever on account of the 
fever, delirium, abdominal pain, and diarrhcea. In trichiniasis the Widal 
reaction is absent, the eyelids are swollen, the muscles are swollen and 
painful, and trichinae may be found in excised muscle tissue. 

In typhus and relapsing fevers the onset is sudden and the defervescence 
is critical. 

The Clinical Varieties of Enteric Fever. — 1. The mild form. All the 

symptoms are mild, the temperature does not go above 103°, and the disease 
does not generally last more than two weeks. 

2. The ordinary form, without special or severe complication, has been de- 
scribed under "symptoms," and a typical case is illustrated by the fever chart. 

3. The abortive form lasts about two weeks and terminates with con- 
siderable sweating. 

4. The latent, or walking, typhoid (ambulatory typhoid). The symp- 
toms for the first two weeks may be exceedingly mild, and the afflicted 
person is able to attend to work, but is eventually compelled to go to bed. 

5. The grave, or severe, form. The fever is high (105°) and may persist 
for five, six, seven, or eight weeks. Most of the classical symptoms of 
enteric fever are present and severe. 

6. Enteric fever in the aged shows a lower fever range and more pro- 
nounced cardiac, pulmonary, and renal complications. 



TREATMENT OF TYPHOID FEVER 



623 



7. In the so called hsemorrhagic typhoid the purpura and the hemor- 
rhagic diathesis occurring during the course of enteric fever are secondary 
and associated with septic complications. These cases are not to be con- 
founded with cases of intestinal haemorrhage occurring during the course of 
enteric fever. 

8. Finally, it may be emphasized that persons may have typhoid ba- 
cilli in their stools without symptoms. 

9. Paratyphoid fever. The Widal reaction is absent, while from the 
blood is obtained a bacillus intermediate in type between the typhoid and 
the colon bacillus. The paratyphoid bacillus may be defined as a member 
of the intermediate group which produces typhoidal symptoms in man. 
The fever is usually mild. The number and frequency of the complications 
form a striking feature of the disease. The surest way of making the 
diagnosis is to cultivate the paratyphoid bacillus from the blood of the 
suspected case. But if the organism cannot be recovered from the blood, 
urine, faeces, or some localized lesion, the diagnosis is justified, in the light 
of our present knowledge, if the blood agglutinates a paratyphoid bacillus in 
high dilution and fails to agglutinate the typhoid bacillus or agglutinates it 
only in very low dilutions. There are two kinds of paratyphoid bacilli, A 
and B, and the blood should be tested with both, as in some cases a nega- 
tive reaction will be given with one and a positive reaction with the other. 

10. Typhoid fever in children usually runs a milder course than in adults. 
Prognosis. — The disease is self-limited. The mortality varies from 5 

to 15 per cent. When death occurs it is usually due to circulatory failure, 
haemorrhage, perforative peritonitis, or some other complication. 

Pregnant women are liable to abort during typhoid fever. 

Valvular heart disease adds to the gravity of typhoid infection. 

Treatment of Typhoid Fever 

The patient must be put to bed and isolated, and all precautions men- 
tioned in the chapter on Prophylaxis and Disinfection must be taken. 

The value of antitoxic serum as a prophylactic and curative agent is 
not as yet established. Before the diagnosis is certain an adult patient 
may take one dose of quinine and calomel, 10 grains each, to be followed 
by a saline cathartic. 

Daily flushing of the lower bowel with soap suds or a warm saline solution 
is indicated as a routine procedure except in peritonitis. 

Diet. — The diet must be fluid and supply fuel to prevent tissue waste. 
It must be readily digestible, leaving but little residue to mechanically 
injure the diseased bowel, which is always affected in this disease. 

Specimen Diet. — Milk with lime water or with Vichy water; white of egg 
in water (whites of two eggs to one pint) ; eggnog ; gruel, oatmeal and barley; 
burnt flour gruel (in diarrhoea) ; ice cream, water ices, blanc mange, custard; 
pea, rice, beef, chicken, and tomato soups; tropon in mint tea, buttermilk, 
matzoon, cream and coffee, milk and tea, cocoa, ginger ale, whiskey, pine- 
apple and orange juice, cold water in abundance. (See also Fluid Diet.) 

When milk disagrees with a patient and whenever the abdomen becomes 
markedly tympanitic, the use of milk should be discontinued. 



624 



INFECTIOUS AND CONTAGIOUS FEVERS 



Liquid diet should be adhered to until the temperature has been normal 
for a week, after which soft diet may be allowed. (See Soft Diet.) 

To aid digestion, 5 drops of dilute hydrochloric acid, in water, should be 
given after each feeding. 

Competent nursing will prevent parched lips, foul tongue, sordes, and 
bedsores. In uncomplicated cases of typhoid fever medication is unnecessary. 
The so called intestinal antiseptics are useless or harmful, and antipyretic 
drugs are of doubtful value. The best intestinal antiseptic is bowel action. 

Hydrotherapy. — The sponge bath is a convenient procedure in private 
practice. The patient is sponged on a blanket. Considerable friction is 
applied, and the temperature of the water may range from 70° to 60° F. 

Cold water may be applied by means of a moist compress placed around 
the chest or over the abdomen. Such applications may be changed every 
hour or two. When a moist cold compress is placed so as to envelop the 
body, we speak of a sheet bath. Cold water may be poured onto the sheet 
while friction is applied. 

A full bath, or "tub," is best given by placing the patient in water of 
from 85° to 90° F. and gradually reducing the temperature to 80° and 70° F. 
while friction is applied. A full bath at 70° is for robust people. Children, 
the aged, and the weak do not take kindly to a cold bath. 

By hydrotherapy we attempt to bring on a reaction to equalize the 
circulation and to promote elimination. 



Treatment of Complications and Sequela 

Pain and Tympanites. — Discontinue milk, apply hot turpentine stupes 
to the abdomen, use a rectal tube to aid in expelling gas, and give a soap 
suds enema. Give turpentine emulsion internally. 

Py Spir. terebinth., ) __ 

Spir. lavandul. co., ) aa ' 

Pulv. gum. arabici, 3ij; 

Syrup., 5jv; 

Aquse, ad, gjv. ! 

M. Sig. : A teaspoonful every two hours until the patient is relieved. 

Codeine may be given to relieve pain. 

Diarrhoea. — Loose stools are the rule in typhoid fever. In case of an 
active diarrhoea, the use of milk should be discontinued and the diet should 
consist of egg, barley gruel, burnt flour gruel, and pea soup. The patient 
may take a teaspoonful of paregoric or bismuth, gr. xv, and opium, gr. \, or 
tannin, gr. v, and opium, gr. \, or 



Py Bismuth, subcarb., 5j; 

Extr. krameriaj fluid., 5j; 

Aquae, 5jss; 

Syrupi, 5jv. 



M. S. : A tablespoonful several times a day. 

Constipation is readily overcome by means of an enema or a saline 
laxative. 



INFLUENZA 



G25 



Retention of urine must be relieved twice or three times a day by means 
of a clean catheter. 

Nervous symptoms and psychoses are best controlled by the usual hydro- 
therapeutic measures. An ice cap and a cold pack may be applied, and 
chloral hydrate and potassium bromide be administered by the mouth or 
per rectum, also morphine, gr. J to \, or hyoscine, gr. jot, ma y be injected 
hypodermically or given by the mouth. Tetany is a rare complication. 

In the event of haemorrhage from the bowel or elsewhere, absolute rest 
is imperative. Opium, gr. \, morphine, gr. J, acetate of lead, gr. ij, or 
tannin, gr. v to x, may be given several times a day. One or two ice bags 
are to be placed on the abdomen and bowel irrigation must be dis- 
continued. 

In circulatory failure we adopt timely stimulation by means of whiskey, 
champagne, strychnine, camphor, digitalis, and enteroclysis at 110° F. 
(See General Therapeutics.) 

Venous Thrombosis. — In peripheral thrombosis with phlebitis, rest and 
an ice bag over the seat of inflammation are indicated. In septic phlebitis 
pus and ichorous fluid must be evacuated by the knife. Ultimately massage 
is useful to overcome local oedema. In 'pericarditis and septic parotitis, 
mastitis, and orchitis, laxatives and an ice bag are indicated. 

Periostitis with bone necrosis and pyothorax are to be treated surgically. 

Pneumonia, pyelitis (pyuria), gangrene, bedsores, and the typhoid spine 
are among the many complications observed in typhoid fever. Peri- 
chondritis of the larynx is comparatively rare. Baldness, temporary or 
permanent, after typhoid fever is not infrequent. Hair cutting and shaving 
the scalp have no marked influence in preventing baldness. Convalescents 
require tonic management in restful surroundings. 

Perforation and Peritonitis. — Perforation of the intestine is usually fatal. 
It occurs in about 2 per cent of all cases. It is announced by a sudden 
severe pain, usually in the right iliac region, accompanied by symptoms 
of collapse and followed by abdominal distention and peritonitis. The site 
of perforation is usually in the last twelve inches of the ileum, and when 
such complication is recognized, the patient must be stimulated and pre- 
pared for an operation if the circulation is not absolutely bad. 

INFLUENZA 

Definition. — Influenza is an acute infectious disease due to the invasion 
of a specific bacillus. It is a disease of very rapid extension and wide dis- 
tribution, and usually occurs in epidemics. The bacillus is small, non- 
motile, and found in large numbers in the nasal and bronchial secretions. 
There is a short period of incubation, varying from twenty-four to 
seventy-two hours. 

Symptoms and Clinical Varieties. — The onset is usually with fever and 
is abrupt; the subsequent course of the disease depends upon the type it 
follows: Respiratory, gastrointestinal, nervous, or febrile. 

In the respiratory type the onset occurs with a catarrhal inflamma- 
tion of the mucous membranes, accompanied by severe prostration. The 
inflammation may involve only the nasopharynx, extend to the larynx or 



626 



INFECTIOUS AND CONTAGIOUS FEVERS 



bronchi, or involve the lung tissue itself. If the lung tissue is involved, it 
is usually in a small area or in the form of a lobular pneumonia. There 
may occur, however, a lobar pneumonia, due to this bacillus. Pleurisy is 
a very rare condition as a primary inflammation, but it is associated with 
pneumonia. Empyema frequently follows a pleurisy of this type. Preced- 
ing tuberculous inflammation of the lung is aggravated by influenza, and 
the damage to the lung tissue by severe influenza frequently produces a 
fertile soil for subsequent tuberculous infection. 

When the gastrointestinal tract is involved, there may be nausea and 
vomiting, together with diarrhoea, as the fever sets in. These symptoms 
may be very severe and be accompanied by collapse. Abdominal pain is 
often the most severe complaint. Jaundice may occur when the inflamma- 
tion of the mucous membrane of the duodenum and common bile duct 
causes obstruction to the escape of bile. Enlargement of the spleen will 
depend upon the duration and intensity of the infection. 

Nervous Type. — The infection may be ushered in with severe headache, 
pain in the back and joints, and marked prostration, but no catarrhal in- 
flammation. Later the meninges and brain substance may be involved 
by the infection and an abscess may develop. The sequelae of such an 
infection may be only mental and nervous depression, or develop into 
melancholia and dementia. This is not a frequent type. 

The febrile type may simulate typhoid fever by continuing for several 
weeks. There may be remissions with chills, so that malaria may be thought 
of. Herpes is a common association, while iritis, otitis, endocarditis, 
phlebitis, and orchitis are less common. Nephritis may develop and be 
severe or become chronic. Of all these types the catarrhal, affecting the 
respiratory system, is the most common, but the other types should not 
be forgotten or overlooked. 

The differential diagnosis is easy when the disease is pandemic. But 
the prostration, out of all proportion to the intensity of the disease, is the 
most characteristic feature to be remembered. The presence of the bacillus 
in the sputum is diagnostic, but such discharge is not present in all types. 
This point can be depended upon only when the disease is of the first type. 

The treatment should be that of all infectious diseases — by isolation, 
confinement to bed during the period of fever, and good, intelligent feeding, 
i. e., with liquid and soft diet, and hydrochloric acid to aid digestion. The 
bowels should be early and thoroughly opened with calomel or salines. In 
the early stages the old treatment with a warm bath, confinement to bed, 
and hot drinks does great good and frequently gives immediate relief. 

If the temperature is high or there is delirium, the coal tar drugs may 
be used, but guardedly, because of their depressing effect upon the heart. 
The ice cap is always useful. Cardiac stimulants (see Stimulants) may be 
required and should then be given. Elixir of strychnine, quinine, and iron 
is excellent during convalescence. Prolonged rest and change of climate 
may be required in some cases to restore the patient to his former health. 

Influenza in Children. — Out of 2,460 examinations of cultures made by 
the Chicago health board from the throats of persons suspected to have 
diphtheria, 677 showed the Pfeiffer influenza bacillus to be the only patho- 
genic organism present. The catarrhal type of influenza is the one most 



YKLLOW FKYEK 



627 



frequently met with in children. The nervous, circulatory, and febrile 
phenomena in influenza are due to the blood intoxication. Children of any 
age are susceptible to influenza infection. Relapses during convalescence 
are quite common, and grave sequelae are frequent. The treatment is purely 
symptomatic, as in other infectious fevers. Sodium benzoate or phenace- 
tine may be given in two grain doses several times a day to restless children. 

YELLOW FEVER 

Definition. — This is an acute infectious disease characterized by severe 
toxaemia, jaundice, albuminuria, and a pronounced tendency to gastric 
haemorrhages. 

iEtiology. — The specific bacillus has probably been isolated by Sana- " 
relli, though this is as yet disputed. 

All races and ages are liable to the disease, though the negro is less 
susceptible. Residents of localities where the disease prevails are less 
susceptible than strangers. Crowding, bad drainage, lack of proper ventila- 
tion, and hot seasons especially favor epidemics. 

The infection is disseminated by the excreta and by mosquitoes, which 
carry the blood and inoculate those who are subsequently attacked. Those 
infected with the disease show in the blood an agglutinative reaction to the 
bacillus of Sanarelli as early as the second day. This fact may be used as 
a means of diagnosis, and it also tends to demonstrate that the bacillus 
is the specific germ of the disease. Immunity is acquired by one attack 
of the disease, but probably not by heredity. 

The incubation period may be as short as twenty-four hours, though it 
usually varies from three to four days. Rarely does this period extend to 
seven days. 

Symptoms. — The onset, as in all acute infectious diseases, is sudden, 
with headache, backache, and chilly sensations. The fever rises rapidly, 
with a hot dry skin. The tongue is coated and moist and the throat is sore. 
Nausea and vomiting accompany the onset and the vomiting increases in 
intensity on the second and third days. The bowels are usually constipated. 

With the onset the face is flushed more than in other acute diseases 
and the conjunctiva is bright red in color. This injection of the capillaries, 
together with jaundice, is the most characteristic feature of the disease. 
After the onset the temperature usually varies between 102° and 103° F., 
and will remain so for the first day. Extremes of temperature are between 
100° and 106° F. By the end of the third day defervescence may begin 
in mild cases, preceded by lysis of two or three days' duration. This 
stage of calm is succeeded by a secondary fever of one, two, or three days' 
duration; then there is a short lysis, and convalescence begins. 

The pulse at the outset is rarely over 100 or 110, but on the second or 
third day, while the rise of temperature persists, the pulse becomes slower 
and may even fall twenty or more beats. During defervescence the pulse 
may fall to thirty. This slowing of the pulse, with a high or rising tempera- 
ture, is another feature of the disease. 

By the third day albumin appears in the urine, especially that voided 
during the latter part of the day. In severe cases the albumin appears 



628 



INFECTIOUS AND CONTAGIOUS FEVERS 



on the first or second day, and the amount is large, with casts and all the 
other signs of acute nephritis. The patient may die of suppression of urine, 
in convulsions or coma. 

From the onset vomiting is present and consists of the stomach contents, 
then of mucus, and then of a grayish fluid. In the second stage the vomiting 
is more continuous, and in severe cases is characterized by the presence of 
blood. It is this blood which gives the name "black vomit," a feature of 
the severe cases, though not necessarily fatal. Small cutaneous haemor- 
rhages or bleedings from the mucous membranes may be present. Black, 
tarry stools result from the presence of blood. As a rule, the mind is 
peculiarly alert, though there may be, in very severe cases, an active delirium 
from the onset. In some cases the first mental change may mark the onset 
of uraemic convulsions or coma. 

Diagnosis. — Yellow fever is to be distinguished from dengue and mala- 
rial fever of a severe type, and the distinction is usually easy if an 
epidemic exists. 

The prognosis varies with the epidemic. The mortality varies from 
10 to 85 per cent. Favorable signs are a low temperature, slight jaundice, 
absence of haemorrhage, and the continued secretion of urine. 

The prophylaxis is to exclude possible sources of infection, isolate cases, 
disinfect all excreta, and institute proper hygiene in infected districts. 
A notable instance of what proper drainage and attention to other details 
of the health of a city can accomplish is to be found in Havana under the 
recent changes there consummated. 

Treatment. — The immediate treatment of the disease depends on good 
nursing and proper relief of symptoms, though a cure by blood serum in- 
jections may at any time be perfected. 

Comfortable, airy, and well but not brightly illuminated rooms, wards, 
or tents are to be preferred. The feeding by the mouth should be with 
very small amounts of fluid, but if vomiting is severe feeding by the mouth 
should not be attempted. Resort to rectal feeding and irrigation if vomit- 
ing is continuous. The withholding of all food in the early stage is prob- 
ably the preferable method in severe cases, and administering rectal saline 
enemata to allay the thirst. Small pieces of ice may be given by the mouth. 
For the pain, morphine may be required. If the temperature is high, bath- 
ing is the best method of treatment. Hot baths are to be used for the 
uraemic conditions if they develop. Cardiac weakness may require stimu- 
lants. Complications are to be met with the appropriate treatment as they 
arise. 

TYPHUS FEVER 

Definition. — This is an acute infectious disease, characterized by a 
sudden onset, a macular rash, and marked nervous symptoms, and termin- 
ating by crisis at the end of two weeks. 

Symptoms and Course of the Disease. — It is very contagious and few 
escape who are exposed. Crowding and poor food seem to increase the 
liability to infection. The virus of the disease has not yet been discovered. 

The incubation period of the disease varies from twenty-four hours to 
twelve days; seldom or never is it over three weeks. 



TYPHUS FEVER 



629 



The invasion is abrupt, with a chill, fever, headache, pain in the back 
and legs, and early prostration. The tongue is dry, furred, and white; the 
face is flushed and the expression dull and stupid; the eyes are congested; 
the temperature is high and may be higher on the second or third day; the 
pulse is full and frequent, seldom dicrotic; and the respiration may or may 
not be hastened. Vomiting may be present, though it is not common. 
Constipation is usual, though diarrhoea may occur. The mental symptoms 
appear early, and in severe cases may amount to violent delirium, worse at 
night. During the second week the delirium is usually of the active, noisy 
variety. The eruption appears at any time from the third to the fifth day, 
first upon the trunk and then upon the extremities. In two or three days 
the rash is all out, and the earliest subcuticular mottling has changed to 
distinct rose colored papules, and these in turn to petechial areas not affected 
by pressure. In the early grouping and appearance, the rash may resemble 
measles or the early rash of syphilis. 

The fever rises with slight remissions for four or five days, reaching the 
maximum of 105° to 106° F. about the fifth day. In mild cases the maxi- 
mum may never be above 103° F. Preceding the fatal termination, the 
temperature may rise to 108° F. or higher. Ordinarily, after the fastigium, 
the fever continues with only slight remissions until the twelfth or fourteenth 
day, when it ends abruptly by crisis. Early in the disease there is a soft 
systolic murmur at the apex with an inaudible first sound. The pulse is 
frequent and feeble. In the second week the frequency may be as high as 
from 150 to 160 to the minute, while the heart sounds resemble closely the 
foetal rhythm. The dusky hue of the face shows the impaired circulation. 

During the second week all the symptoms become greatly aggravated, 
especially those arising from the cerebrum. The prostration is much more 
marked, the patient lying upon the back, with a dull, expressionless face; 
the cheeks dusky or flushed, the conjunctiva injected, and the pupils con- 
tracted. Frequently there is coma vigil, with subsultus tendinum and 
picking at the bedclothes. The tongue becomes dry, brown, or black and 
cracked — the so called "parrot-tongue" of typhus. The normal ratio of 
pulse and respiration is not usually altered, unless there are complications 
or the delirium is unusually active. 

In the favorable cases the temperature falls on the fourteenth day and 
the patient passes into a quiet sleep which leaves him with a clear mind. 
A profuse clammy sweat at this time is usually a bad sign, showing a severe 
grade of prostration. 

Convalescence is usually rapid and relapses are very rare. The con- 
gestion of the lung to a more or less marked degree is a common feature of 
severe cases. Pneumonia is the most frequent complication. The urine 
shows an increase of the urea and uric acid; the chlorides are diminished; 
albumin is present, but rarely nephritis. There may be hsematuria. 

There are malignant cases which terminate in a few hours or in two or 
three days. Contrasting with these are. the mild cases sometimes seen in 
epidemics. 

Complications. — Pneumonia is usually of the bronchial type. Gangrene 
may occur, and it is fatal. In children cancrum oris, or infection of toes, 
hands, or nose, may occur. Meningitis is rare, while subsequent paralysis 



630 



INFECTIOUS AND CONTAGIOUS FEVERS 



is not uncommon. Septic processes, in addition to those mentioned, may 
occasionally happen. Nephritis is uncommon, while hematuria is more 
frequent. 

Prognosis. — In the young, about 12 to 20 per cent of the cases are fatal, 
while after middle age the mortality is about half. In the second week 
death is usually due to the toxsemia, while after that period death is generally 
caused by a complication, most commonly pneumonia. 

Diagnosis and Differential Points. — Diagnosis is extremely difficult, 
except during an epidemic. The Widal reaction, if present, establishes the 
diagnosis of typhoid fever. H cemorrhagic variola may resemble typhus, 
but the hard, shotty area may help to distinguish it if the distribution of 
the initial rash does not. 

Cerebrospinal meningitis must be thought of, but spinal puncture 
and the character and distribution of the eruption will help to distinguish 
the one from the other. 

Measles has a brighter rash, and its appearance is preceded by catarrhal 
symptoms. 

Syphilitic eruptions occur with slight fever or none at all, and the history 
of chancre. 

The treatment of typhus should be the same as for typhoid fever — 
comfortable, airy quarters with an easy bed and competent, skilled nurses. 
The feeding should be at regular intervals, and the food should consist of 
milk, eggs, broths, and gruels. Peptonized preparations may also be used 
when the digestive power is weak. Water should be administered in good 
quantities, to allay the thirst and help to reduce the fever and dilute the 
toxines in the blood, thus aiding in the excretion of them. 

Alcohol should be used, as in typhoid fever, to conserve the energy of the 
patient. The good effect will be seen by the action of the heart becoming 
slower and more forcible; by the delirium or nervousness growing less active; 
by the tongue becoming moist and cleaner; and by the sleep being of longer 
duration and more tranquil. 

Cold baths should be used on the same indications as in typhoid fever, 
to reduce the temperature and act as a tonic to the circulation and the 
nervous system. 

Camphor, strychnine, caffeine, and digitalis should be used as indications 
require. The intestinal tract should be cleared with mild cathartics at 
intervals. 

Complications require the treatment directed to such conditions. 

DENGUE 

This is an acute infectious disease, characterized by fever, pain and 
swelling of the joints, and an erythematous eruption. 

^Etiology. — The cause of the disease is not known, though a micro- 
coccus and a hsematozoon have both been given the credit. Tropical and 
subtropical countries are most affected by epidemics, and these are very 
rapid in diffusion. Because of its frequency in places where, and at seasons 
when, the mosquito is most numerous, the culex is believed to be the vehicle 
of the infection. 



DENGUE AND RELAPSING FEVER 



631 



Symptoms. — After an incubation period of from three to five days, the 
onset is sudden, with headache, intense joint pains, and pain in the muscles. 
There may be a chill. The temperature gradually rises and may reach 
106° or 107° F. The pulse becomes frequent with the high temperature. 
The face is bloated and suffused, while the mucous membranes are injected. 
The conjunctiva is especially notable for the injection. The usual con- 
comitant symptoms of infectious fevers are present, viz.: loss of appetite, 
a coated tongue, constipation, and a diminished amount of urine. The 
joints are successively involved and become swollen, red, and painful, 
but do not suppurate. Haemorrhage from the mucous membranes and black 
vomit have been noted in some epidemics. 

About the third or fourth day the fever reaches the maximum, and 
then follows a period of from two to four days of apyrexia. During this 
period the patient is prostrated out of all proportion to the severity of the 
fever. Following the apyrexia, another attack of high temperature, with 
return of all the joint symptoms, occurs. Accompanying the attacks there 
are various eruptions, but none distinctive — macular, papular, scarlatini- 
form, urticarial, or vesicular. The usual duration of the disease is seven 
or eight days, and it is followed by mental and physical depression of a 
severe nature. 

Diagnosis. — In epidemics the diagnosis from rheumatism and yellow 
fever is not easy, even when all the symptoms are closely observed. The 
agglutination test for yellow fever, if positive, is of diagnostic importance. 

In the treatment there is no specific as yet, though serum therapy may 
in the near future give us an antitoxine. Relief of pain with opium or 
morphine, careful nursing, fluid diet, and hygiene are the elements of treat- 
ment, with tonics and stimulants in convalescence. 

RELAPSING FEVER 

Definition. — This is a specific infectious disease caused by the spirochsete 
or spirillum of Obermeier and characterized by a febrile paroxysm of six 
days' duration, followed by a remission of about the same duration, then 
a second febrile attack and a remission. There may be three or four remis- 
sions or only one. 

The disease is very contagious, but how it is conveyed is unknown. 
Overcrowding and poor food dispose to the disease, while age, sex, and 
season are not factors. One attack does not confer immunity to a second 
attack. 

The spirochsete is found in the blood during the fever. It varies in 
length from three to six times the diameter of a red corpuscle. It is a 
narrow, spiral filament, active and readily found during the paroxysm. 
During the remission bright glistening bodies are found in the blood, but 
whether these are spores or specimens of destroyed spirochsete is yet dis- 
puted. 

The incubation period is supposed to vary from a few hours to three 
weeks, but is usually from five to seven days. 

Symptoms. — The invasion begins abruptly with a chill, fever, and pain 
in the back, limbs, and joints. Young people may have nausea and vomit- 
41 



632 



INFECTIOUS AND CONTAGIOUS FEVERS 



ing or even convulsions. Soon after the onset the temperature rises and 
may vary from 104° to 108° F. The pulse varies from 110 to 130. The 
tongue is coated and vomiting may persist. Sweating may be present 
with the prostration. The spleen enlarges early and jaundice may develop, 
which indicates a severe form of the disease. There is no characteristic 
eruption, though there may be a roseola, mottling of the skin, or petechial 
spots. Herpes may also develop. There is usually leucocytosis. At any 
time from the fifth to the seventh day the crisis may occur, with sweating, 
diarrhoea, and sometimes collapse. Sometimes epistaxis or haemorrhage from 
the stomach or bowels may accompany the fall in temperature. For about 
a week the intermission persists, when a return of all the previous symp- 
toms may occur. The second crisis may occur at the end of a week. There 
may be four or five relapses. Some cases terminate with the first crisis. 

Prognosis. — The disease is fatal in about 4 per cent of the cases. In 
feeble and aged individuals death may occur in the first attack. 

Complications are not frequent. Nephritis and haematuria may occur. 
Pneumonia and paralysis are not frequent complications. Pregnancy usu- 
ally terminates in abortion. 

The diagnosis of the disease is certain when we find the organisms in 
the blood. 

Treatment. — Hygiene, fluid diet, and careful nursing are the most effect- 
ive elements of treatment. No drug affects the course of the disease. If 
collapse occurs, treatment directed to that condition is necessary. Severe 
pain may require opium. There is here a splendid opportunity for serum 
therapy, since the blood alone contains the cause of the disease. 

CHOLERA ASIATICA 

Definition. — This is a specific infectious disease caused by the comma 
bacillus of Koch and characterized by violent purging and vomiting, rapidly 
terminating in collapse. The bacillus is a bent rod, or spirochete, slightly 
shorter and thicker than the Bacillus tuberculosis, found in pure cultures 
in the rice water stools. The toxines produced by this organism are espe- 
cially active, and a very active antitoxine is produced in the blood of those 
who recover. The artificial antitoxine has been used in large quantities in 
India, has proved its prophylactic and curative power in many cases, and 
is worthy of trial in every case. The bacillus is readily killed by drying or 
boiling. 

As a disease, cholera is not highly contagious, depending for its spread 
upon infection of the susceptible gastrointestinal tract of the victim. 
The bacillus is contained in the vomitus and stools, and hence these are 
the chief sources of infection. Some individuals are more susceptible than 
others to the infection, and innocent diarrhoeas are fertile soils for the 
cholera bacillus. All ages and races are prone to the infection. Fruits and 
vegetables partly decayed, infected water and vessels, and the ubiquitous 
fly are all carriers of the infection. Communities at the sea level are more 
frequently infected than those at greater altitudes, probably because of the 
commercial exposure to infected immigrants. 

One attack does not immunize to a second. 



CHOLERA ASIATICA 



633 



Symptoms.— There is usually an incubation period of one or two days, 
with diarrhoea and possibly vomiting. There may be accompanying 
headache and mental depression. The temperature may not rise in this 
early stage. The diarrhoea increases and profuse watery evacuations occur 
in rapid succession as the stage of collapse sets in. Accompanying this active 
purging are colicky pains with tenesmus and cramps of the legs and feet, 
together with exhaustion. As collapse occurs, the features are pinched 
and shrunken, with an ashy gray skin covered with cold, clammy sweat. 
Later cyanosis is evident as the collapse becomes more extreme and the 
heart's action grows very rapid and feeble. The tongue is coated white 
and dry. The temperature of the mouth or axilla may be five or ten degrees 
below normal while the rectal temperature will be 103° or 104° or more. 
This condition may pass on to coma and death, or may be followed after 
a short duration by a period of reaction.- During the stage of collapse 
the urine is diminished in amount, and this is due to the tremendous drain 
of fluids from the circulation and the body in general. The faeces are at 
first bile stained and yellow, changing to grayish white and later to the 
turbid "rice water" stools characteristic of the disease. "Rice water" 
stools consist of mucus, granular detritis, blood, and the fluid exudation, 
which contains albumin, the salts of the blood, and bacteria. The amount 
of fluid extracted from the circulation by the diarrhoea accounts for the 
circulatory disturbances common to the disease. The cases of sudden 
death before the purging begins are known as " cholera sicca," or dry cholera. 
Mild cases are known as "cholerine." 

If the stage of collapse does not terminate life, the reaction period sets 
in, and we observe a steady improvement. The cyanosis disappears. The 
cold, clammy skin becomes warm and dry. The pulse becomes stronger 
and full. The temperature may rise. The urine increases in amount. 
The diarrhoea becomes less active, and abdominal pain disappears. Every 
feature improves and convalescence is soon established, the patient feeling 
well in three or four days. This is the picture of the average case. 

Instead of the uneventful recovery, there may be a relapse and return 
of all the worst features, with death in coma. Deaths in such cases have 
been attributed to uraemia from suppression. 

During epidemics there may be all grades of severity, but the general 
features and a bacteriological examination will determine the diagnosis. 
Complications are not common, and they usually occur in those organs most 
affected in their circulation. Nephritis may develop, but is not common. 
Colitis may follow the intestinal irritation. Pneumonia and pleurisy some- 
times occur. Other complications may occur, but are not common. 

Diagnosis. — The diagnosis of the disease is easy when an epidemic exists, 
but cholera must be distinguished from poisoning due to drugs, such as 
arsenic or bichloride of mercury, or the ptomaines of food or fungi. 

Prognosis. — The prognosis is uncertain and varies in the different epi- 
demics between 30 and 80 per cent. 

Treatment. — The treatment is prophylactic and medical, as in all in- 
fectious diseases. The preventive treatment depends on the isolation of 
patients, prevention of the general spread of the infectious stools, etc. 
Hence all clothes and bedding, together with all the stools, urine, vomitus, 



634 



INFECTIOUS AND CONTAGIOUS FEVERS 



etc., should be thoroughly disinfected before their final disposition. The 
water used for drinking, washing, etc., should be pure and free from possible 
contamination. The diet when epidemics exist should be carefully attended 
to and errors should be avoided. 

If suspicion of an attack or a diarrhoea begins, early intelligent treat- 
ment should be instituted, thus preventing the exposure of a fertile soil. 
Once the disease begins, opium or morphine should be used hypodermically 
to control the diarrhoea, and acetate of lead and large doses of bismuth may 
also be used to aid in controlling the purging. 

For the vomiting, lavage may be used early. When collapse sets in, 
enteroclysis of a warm saline solution may be given to replace somewhat 
the loss due to the severe purging. Heat externally should also be used to 
overcome the shock of collapse. Hypodermoclysis and infusion of a saline 
solution into the arm should be used if the circulation becomes greatly 
embarrassed. Together with the above mentioned measures, the hypo- 
dermic use of ether, camphor, and strychnine may be required by the con- 
dition of the heart. It is in this stage of the disease that close watching 
and careful treatment may turn the tide in favor of the patient; hence 
the value of careful, expert nurses and physicians. Following the collapse, 
the patient will need careful regulation of the diet to insure a continued 
convalescence or completion of the reaction stage. 

VARIOLA 

Definition. — This is an acute infectious disease characterized by an 
eruption which passes through the stages of papule, vesicle, pustule, and 
crust. It is usually regarded as the type of the exanthemata, because of 
the four stages of the eruption. Dr. Councilman, of Boston, professes to 
have discovered the specific cause to be a protozoon. 

Age and sex have little or no influence upon the susceptibility, though 
the colored race particularly are said to fall ready victims to its virus. 
The fatality in blacks is about 42 per cent and in whites about 35 per cent. 
The more frequent exposure of colored persons, because of their usual func- 
tion of servant and laundress, is probably the real explanation of their 
greater death rate. 

The contagion is developed in the body and given off in the secretions 
and excretions. That it may retain its virulence for long periods in districts 
once infected has been demonstrated. The retention of infection in clothes 
has been reported after seventeen years. As in the other exanthemata, 
mild attacks may follow exposure to severe cases, and, conversely, severe 
infection may result from exposure to very mild cases. 

Clinical Varieties. — In describing the disease, it is customary to dis- 
tinguish three forms, two of which are again subdivided, depending upon 
the severity of the symptoms, as follows: Variola vera, (a) discrete; (b) 
confluent. Variola hemorrhagica, (a) purpura variolosa, or black smallpox; 
(6) variola pustulosa, or hsemorrhagic pustular form. Varioloid, smallpox 
modified by vaccination. 

Symptoms. — Unless death intervenes, there are four stages to each form, 
viz. : incubation, invasion, eruption, and desiccation and devastation. 



VARIOLA 



635 



Incubation. — This period may vary from eight to twenty days, usually 
lasting between nine and fifteen. During this period there is seldom any 
complaint other than of "malaise." 

Invasion. — This is sudden, with a chill in adults and convulsions in 
children, and a rapid rise of temperature, which may reach 103° or higher. 



PRUSSIA. 

With compulsory vaccina- 
tion and compolsory re- 
vaccination attheageofl2. 



Defore the 



After the Law of 
1874 was Passed. 



1863-1874 

Average 
yearly Deaths 
from Small 
pox in every 

100,000 
inhabitants. 



II....IL. 



Annual Deaths 
from small pox 
Id every 100,000 
Inhabitants. 



HOLLAND. 

With compulsory vaccination of 
children before entering a 
school. 



Before the 
Law 



After ohe Law of 1373 
ttssed. 



Il-ul 



i.l.i 



1S6&-1872 
Average 
yearly Dea the 
from small 

lox In every 

100,000 
Inhabitants. 



Annual Deaths from 
small pox in every 
100,000 inhabitants. 



AUSTRIA. 

Without compulsory 
vaccination. 



1S6S-1874 
Average 
yearly Deaths 
from small 
jiox in every 

100,000 
inhabitants. 



Annual Deaths 
from small pc* 
in every 100,000 
inhabitants. 



Fig. 209. — The Value of Vaccination (from Phila. Med. Journal, 1899). 



Severe frontal headache, lumbar pains, and vomiting are constant symptoms. 
The pulse becomes frequent and full, seldom dicrotic. The respirations 
are increased in frequency. The face is flushed and the mucous mem- 
branes of the tonsils and pharynx are dusky. The eyes are bright. The 
general appearance is anxious and restless. With the high temperature 
there may be delirium. On the second or third day of this period the 
variolous rash may appear. Two forms of the rash may be described: 
the diffuse, or scarlatinal, and the macular, or measly. Occasionally, 



636 



INFECTIOUS AND CONTAGIOUS FEVERS 



with either of these, there may be petechias. The extent of the surface 
involved varies, and may vary in the same case from time to time. 

Points of election are usually the groin and inner surface of the thigh, 
the axillae, the pectoral regions, and the inner surface of the arm, but any 
other point may be affected. The surfaces involved may or may not be 
elevated above the surrounding surface. 

The eruption, in the form of round red spots, appears usually about 
the fourth day, on the forehead, at the anterior boundary of the scalp, on 
the wrists, and on the mucous membrane of the mouth. On the second 
day these red areas develop into papules, which in turn, about the sixth 
day, change to vesicles. By the eighth day the vesicles become pustules. 
As the change from clear, umbilicated vesicles to turbid pustules occurs, 
the surrounding tissues become swollen, injected, and very tender. 

With the first appearance of the eruption the temperature usually falls 
and the general symptoms subside, but with the change to pustules the 
temperature again rises, the pulse becomes very frequent, and the suffering 
from the condition of the skin and mucous membranes is very great. There 
may be stupor and delirium, in which the patient continues for from three 
to eight days. The condition of the patient now may be said to be the 
result of a toxaemia from the multiple abscesses, which are infected by 
streptococci and staphylococci. This second rise of temperature and 
return of symptoms, therefore, is pyaemic in character. As the pustules 
become distended their contents are evacuated by the rupture of the re- 
taining wall, either spontaneously from the increased internal pressure or 
by friction from without, and the thick pus is discharged on the surround- 
ing surface and bed linen or clothes. The warmth of the body quickly 
brings about drying of this mucilaginous material, with the subsequent 
crust formation. Rupture of the pustules does not occur everywhere at 
once, but rather in the order of the appearance of the rash. With this 
maturation, crusts are formed, and the general condition and appearance 
of the patient are repulsive. 

The eyelids are swollen, cedematous, and glued together with thick 
crusts, making vision impossible. The nasal chamber may be so encroached 
upon by crusts as to prohibit breathing by the normal passages. The 
larynx may be completely occluded by the oedema of the mucous membrane 
and the subsequent vesicle formation, so that at any time tracheotomy 
may be necessary to preserve life. Whether the condition becomes as 
severe as this or not, the loss of voice is usually complete, for the tongue is 
stiffened by the swelling and almost completely fills the mouth. The lips 
are swollen and stiffened and practically immobile. On this account breath- 
ing by the mouth is difficult and feeding is made painful and tedious. 

Desiccation. — During the third week drying of the crusts and decrusta- 
tion proceed rapidly, and the temperature gradually falls to normal, though 
it may not reach that point until the fourth week. Complete scarring may 
not be accomplished for three or four weeks. In some cases complete 
epidermal casts of the hands or feet may be shed. 

Confluent Variola. — In this form of the disease the initial symptoms 
are the same, though usually of greater severity. On the third or fourth 
day the rash appears, but the earlier the appearance of the rash the greater 



VARIOLA 



637 



the probability of the vesicles later becoming confluent. As the eruption 
develops, the skin becomes swollen and hyperaemic and the papules appear 
very close together. The crowding is especially marked on the hands and 
legs, less on the arms and thighs, and usually they are discrete upon the 
trunk. The confluence of the pocks is especially marked upon the hands, 
legs, and face. 

As the eruption appears the symptoms subside somewhat, but seldom 
become so slight as in the discrete form. The temperature may fall to 
normal, but usually it does not. On the eighth day, with the change to 
pustules, the temperature again rises and the swelling and hyperemia of 
the skin are very severe. By the tenth day the maturation is complete 
and we observe large superficial abscesses. The temperature is usually 
high, 103° or 104° F., with a frequent, rapid pulse of 110 to 120. All the 
symptoms of the discrete form are present in this, though in a more severe 
form, and the picture is somewhat more hideous. 

Hemorrhagic Smallpox. — The differential diagnosis between the two 
forms of hsemorrhagic variola depends upon the time of the appearance of the 
haemorrhages. In purpura variolosa the symptoms begin very suddenly 
and severely, usually with chills. It is more common in youth, in females, 
and in pregnancy. This form is rarely if ever seen in those who have been 
vaccinated. By the second or third day there is a diffuse hyperaemic rash, 
especially marked in the groin, and numerous petechia? are to be found. 
As the rash extends the haemorrhages become more marked. There may 
be ecchymosis in the conjunctiva, and as early as the third day severe 
haemorrhages may occur from any point of the mucous membranes. This 
form is regularly fatal and death may occur on the third or fourth day, 
before the rash appears. 

In the second form, or haemorrhagia pustulosa, the haemorrhages occur 
when the change to vesicles or pustules takes place, on the seventh, eighth, 
or ninth day. The earlier the haemorrhages the greater the danger. This 
form is more common in weak men and inebriates. The prognosis is very 
bad. 

An unclassified form has been described in which there are haemorrhages 
during the vesicular stage, followed by a very rapid disappearance of the 
rash and speedy recovery. 

Varioloid. — This is variola modified "by vaccination. It is a very mild 
form, though the onset may be sudden and the symptoms rather severe. 
The temperature may reach 103°, but with the appearance of the papules, 
on the third or fourth day, the temperature drops and the patient feels well. 
The secondary rise of temperature does not occur. With the drop of 
temperature the papules and vesicles begin to disappear. Thus we have 
several names applied to the condition, depending upon the appearance of 
the dried vesicles, such names as horn, crystalline, and wart pox. 

Complications. — These are comparatively few when we consider how 
severe is the disease. 

Laryngitis may be serious in three ways. There may be a fatal oedema. 
With convalescence there may be necrosis of the cartilages. The diminished 
sensitiveness of the mucous membrane may permit the inhalation of par- 
ticles which excite a fatal pneumonia. 



638 



INFECTIOUS AND CONTAGIOUS FEVERS 



Bronchopneumonia is the usual form in fatal cases, while lobar pneumonia 
is a rare condition. Pleurisy is a common complication in some epidemics. 

Cardiac complications are in general rare. A systolic murmur at the 
apex is rather common during the height of the fever, but endocarditis is 
rare. Pericarditis is uncommon, while myocarditis associated with endar- 
teritis of the coronary arteries is more usual. Gastritis, enteritis, or colitis 
is rare. Inflammations of the kidney are rare, while albuminuria during the 
fever is usual. 

Changes in the nervous equilibrium, such as convulsions, or postfebrile 
insanity, are not common. Neuritis is not common, though it is the more 
usual form of nervous disorder. 

The changes in the skin are the most inconvenient complications. Acne, 
boils, and local gangrene do not occur. 

Inflammations of the joints may occur. 

Catarrhal or purulent conjunctivitis is common in severe cases, while 
iritis is uncommon. 

Otitis media does occur, though it is not frequent. 

THE DISTINGUISHING CHARACTERISTICS BETWEEN MILD DISCRETE SMALLPOX 

AND CHICKENPOX 



Age ..... . 

Incubation 
Invasion . 



Surfaces attacked 



Character of the eruption . . . 



Temperature 



Contour of the eruption 



Sensation 

Duration, including period of 
invasion and desquamation 

Vaccination 

Mortality 

Resolution 



Smallpox. 



Any age 

Two weeks 

Marked headache, backache, 
fever, general malaise, last- 
ing three to four days. 

Worse on the exposed parts, 
extremities; invariably on 
the palms. 

Progressive; papules, vesi- 
cles, pustules, crusts; feels 
like shot under the skin. 

Multilocular. 

Remains high (103° to 105°) 
till eruption appears, then 
drops and does not rise 
again for a week, and not 
then in the milder discrete 
forms. 

Quite uniform in size; has a 
reddened area at base; fre- 
quently umbilicated. 

Painful to the touch; may 
itch. 

Two to four weeks. 

Protects 

High in severe confluent and 

haemorrhagic types. 
By crisis 



Chickenpox. 



Childhood usually. 

Thirteen to seventeen days. 

Is none, or at most only slight; 
worse in the covered por- 
tions, thorax. 

Rarely or never seen on the 
palms or soles. 

Papules and crusts; lesions 
very superficial; easy to 
rupture. 

Unilocular. 

Rises with the severity of 
the attack. 



Not uniform; also inflamed 
area about the vesicle, but 
less marked. 

Not painful to touch. 

One week to fourteen days. 

Does not protect. 
Nil. 

By lysis. 



Prognosis. — In those who have not been vaccinated the mortality ranges 
from 25 to 35 per cent in different epidemics, while in those who have been 
vaccinated the percentage of deaths is only about 1.29 per cent. 



VARIOLA 



639 



The hannorrhagic type is usually fatal. High temperature, delirium, and 
subsultus are grave symptoms, while severe laryngitis or pharyngitis is fatal. 

Diagnosis and Differential Points. — In the early stages the rash may be 
confounded with that of scarlatina, measles, or cerebrospinal meningitis. 
Later varicella, the pustular form of glanders, and pustular syphilis have 
to be thought of. During epidemics the distinction is usually easy. 

Treatment. — The treatment should be directed to the alleviation of 
symptoms and complications as they arise, and, above all things, should be 
rational. 

Prophylaxis should be carried out very minutely, and vaccination of all 
the attendants should be insisted upon. The patient should be vaccinated 
if seen early, during the invasion, as this has seemed to affect the course 
of the disease when performed at this early stage. The clothing, bedding, 
and excretions should be thoroughly disinfected and where possible should 
be destroyed by fire. Crowding of patients should not be allowed, and open, 
airy wards or tents should be used. Free circulation of fresh air should be 
procured. The immediate care of the patient is most important, hence 
competent, faithful nursing is essential. 

The diet must and should be fluid ; hence milk, modified in various ways, 
alternated with good broths, can be relied upon (see Fever Diet). Cold 
drinks should be given in unlimited quantities, thus aiding the elimination 
of the toxines by the kidneys and at the same time influencing the tempera- 
ture somewhat favorably. For high temperatures the cold sponge or bath 
should be performed, remembering always that antipyretic drugs are de- 
pressing and therefore best not administered. 

In anticipation of the crust formation, it is wise to cut short all the hair, 
thus rendering the parts more readily accessible to local treatment and 
diminishing the source of subsequent discomfort. As an aid in softening 
the crusts, an oily fluid, such as vaseline, or some bland oil, may be used. 
Over the face a mask of gauze, kept wet with some weak antiseptic, such as 
carbolic or mercury bichloride, will add materially to the comfort of the 
victim. Cleansing the eyes frequently with a boric acid solution will pre- 
vent the complicating inflammations of the conjunctiva which may other- 
wise occur. The mucous membrane lining the nose and the mouth should 
be frequently and carefully moistened and cleansed, thereby diminishing 
the crust formation and at the same time the obstruction of the passages. 
Care as to these details will add greatly to the comfort of the patient. 

For the cervical adenitis and angina, cold applications on the neck will 
afford relief. If laryngeal or nasal and buccal obstruction develops, so that 
asphyxia is threatened, tracheotomy should be performed. 

Drugs. — In the first stages of the complaint a thorough intestinal purge, 
such as calomel, should be given, thus preparing the tract for the subse- 
quent fluid diet. If diarrhoea develops, it can be controlled by the admin- 
istration of the deodorized tincture or the camphorated tincture of opium 
in frequent small doses. Dilute hydrochloric acid will aid digestion. 

Constipation can be relieved by warm saline rectal irrigations given 
every second day. Enteroclysis is indicated for its stimulating effects. 
A water or air bed should be used if the patient's condition requires it. 
Complications are treated as they arise. 



640 



INFECTIOUS AND CONTAGIOUS FEVERS 



VACCINIA, OR COWPOX; VACCINATION 

Vaccinia is an eruptive disease of cattle the virus of which, inoculated 
into man, produces a pock at the point of inoculation, together with con- 
stitutional changes which render the individual more or less immune to 
variola. The virus is contained in the vesicular lymph, which is known as 
vaccine. Two varieties of vaccine are used — that taken directly from 
the calf, which is known as animal lymph, and that taken from a person 
recently vaccinated, which is known as humanized lymph. The animal 
lymph, obtained from some reliable source, is the best and most common virus 
used in these days of infection studies. 

Inoculation, or vaccination, is performed in the following manner. A 
point on the arm, preferably the left, is selected where the deltoid is inserted 
into the humerus. If, in response to society's demands, the leg is selected, 
a point anterior to and three or four centimetres below the head of the 
fibula is selected. 

The area is now thoroughly washed with soap and water, followed by 
alcohol. While the skin is held on the stretch, cross markings with a 
sterile scalpel, lancet, or needles are made sufficiently deep to bring the 
serum to the surface, but not to draw blood. This area should be at least 
half a centimetre square. The virus, or serum, is now applied and well 
rubbed in. The glycerinated preparations are probably the best, and a 
sterile toothpick may be used to rub in the serum. 

If the old ivory point is used, it is well to dip it in warm water for a 
moment before rubbing it upon the excoriated surface. The virus applied, 
it is well to wait until the vesicles form before protecting the point of inocula- 
tion from the friction of the clothes or other objects. The drying of the 
blood serum at the point of vaccination will prevent possible infection with 
objectionable bacteria until the vesicular stage. Protection is readily ob- 
tained with clean sterile linen or gauze, or best with one of the numerous 
raised shields to be had in the market. A small pill box inverted over the 
area and fastened on with adhesive strips does very well. In applying 
adhesive strips, be careful not to completely encircle the arm with them 
or apply them with tension, as they will cause constriction and set up 
irritation and discomfort about the point of vaccination. Such a raised 
shield may be left undisturbed for a week unless some complication indicates 
its earlier removal for inspection or treatment. 

Symptoms. — After inoculation there is a period of incubation, with 
irritation at the point of application. On the third day a papule, surrounded 
by a zone of induration, appears and enlarges until the eighth day, when it 
reaches its maximum size. The vesicle has raised margins, with a depressed 
or umbilicated centre, and contains a clear, limpid fluid. It is a multi- 
locular vesicle, and hence does not collapse if punctured. About the tenth 
day the areola enlarges and becomes more extensive, while the skin is 
swollen, indurated, and painful. 

On the eleventh or twelfth day hyperemia begins to diminish, the 
lymph becomes more gelatinous, and by the fourteenth day dries into a 
hard brownish scab. From the twenty-first to the twenty-fifth day, the 
scab may separate, leaving a circular, pitted scar, somewhat reddish and 



VACCINATION— BUBONIC PLAGUE 



641 



slightly tender to manipulation. The usual scar changes occur, and after 
an indefinite period a white cicatrix results. 

With or before the appearance of the vesicle, on the third day, constitu- 
tional symptoms more or less severe cause the patient to be restless or irri- 
table. The temperature usually rises and may remain slightly elevated until 
the eighth or ninth day. In children, when first inoculated, the general 
symptoms are as a rule less severe than in second or subsequent vaccina- 
tions. 

Enlargement of the inguinal or axillary glands, more or less severe, 
follows the purulent change of the vesicle. Examination of the blood 
shows a marked increase in the number of the leucocytes. 

The usual time of vaccination in children is from the third to the sixth 
month and whenever an epidemic exists. The duration of immunity is 
variable; in some cases it is absolute; in others of only a few years' duration. 
Revaccination should be done at the age when the child is about to enter 
school and whenever there is an epidemic or exposure of an individual to a 
case occurs. 

The general symptoms of revaccination are usually more severe than those 
of the first. The vesicle is smaller, but the hyperemia and induration are 
apt to be more intense, and the scar is less perfect. The larger and more 
perfect the scar, the greater the immunity seems to be, an observation well 
attested by excellent authority, though no one should refuse to be revacci- 
nated because of a large scar. 

Though the foregoing is the usual course of vaccination, there are numer- 
ous variations, both of the pock and of the general symptoms. Thus, 
there may be a very rapid development with itching, and the lymph early 
becomes opaque, with incrustation on the seventh or eighth day. Again, 
the evolution may be slow and the contents be bloody, or there may be 
ulceration with inflammation. The pock may recur for several weeks. 
Less frequently there may be a general rash on the body. In children 
vaccinia may in rare instances be fatal. 

Complications of vaccinia are due to infection of the wound, either at 
the time or secondarily, by the virus of local or general diseases. Erysipelas, 
syphilis, and tetanus are the most common. It is doubtful if tuberculosis 
is ever inoculated by this means. The possibility of inoculating disease is 
greatly diminished by the use of animal virus from a reliable source, with 
emphasis upon the reliable. 

Vaccination has been advocated for its favorable effects upon pertussis, 
but the effect is doubtful. Chronic constitutional diseases may be given an 
impetus by vaccination, and the rationale may be readily understood. 
The body, with just sufficient resistance to withstand a chronic disease, 
is unable to bear the added load of a new infection; hence both infections 
are more active for the time being, and may leave the organism less able 
to withstand the burden of the chronic disease. 

BUBONIC PLAGUE; PEST; BLACK DEATH 

This disease is an infection by the bacillus pestis with a pronounced 
localization in the lymph nodes in the inguinal axillary, cervical, and 



642 



INFECTIOUS AND CONTAGIOUS FEVERS 



popliteal regions. After three or four days of indefinite septic symptoms 
the glands swell and suppurate or become gangrenous. As in most septic 
diseases, we recognize a mild, a severe, and a malignant form. In the latter 
the poison localizes itself in the viscera or there is a general toxaemia without 
localization. 

The three clinical varieties, the bubonic, the pneumonic, and the septi- 
caemic, may be defined pathologically as follows: 

1. The Bubonic, or Lymphadenal, Variety. — This is a regional lymph- 
adenitis or "typical bubo," characterized anatomically by a chain of 
haemorrhagiconecrotic nodes embedded in serohsemorrhagic oedema. 

2. The Pneumonic Variety. — This occurs as a lobar or lobular consolida- 
tion essentially indistinguishable, histologically, from pneumococcal and 
other bacterial pneumonias. 

3. The septicemic variety, which is a bacillaemia without the association 
of pneumonia, lymphadenitis, or other gross lesions resulting from bacterial 
activity. 

Treatment. — In the present stage of our knowledge the treatment is 
prophylactic and symptomatic. 



CHAPTER XXVI 



DISEASES DUE TO FAULTY METABOLISM, TO FAULTY 
INTERNAL SECRETIONS AND TO DERANGEMENTS OF 
THE DUCTLESS GLANDS 

Synopsis: Gout. — Diabetes. — Obesity. — Scurvy. — Diseases of the Thyreoid Gland. — Myx- 
cedema. — Cretinism. — Basedow's Disease. — Exophthalmic Goitre. — Goitre and New 
Growths. — Diseases of the Suprarenal Gland. — Addison's Disease. — Diseases of the 
Pituitary Body. — Acromegaly. — Diseases of the Spleen. — Diseases of the Thymus 
Gland (vide Paediatrics and Mediastinal Disease). 

GOUT 

Definition. — A constitutional disorder characterized by paroxysmal at- 
tacks of inflammation of joints, associated with the formation of chalklike 
concretions in and about the joints and in other parts of the body. 

The term lilhamia is sometimes applied to the disposition toward the 
formation of the gouty concretions and calculi. 

Podagra, cheiragra, gonagra, and cleidagra are terms employed to indicate 
the point of local inflammation, as for pain in the metatarsophalangeal 
joint, the metacarpophalangeal joint of the thumb, the knee joint, and the 
sternoclavicular joint respectively. 

When a gouty joint is dissected after death, the articular cartilages are 
found encrusted with a white mortarlike material, which upon analysis is 
found to be sodium biurate. It is found in specks, streaks, and patches, 
and may be confined to the articular cartilages or extended to all the struc- 
tures about the joint, such as ligaments, fascia?, tendons, synovial mem- 
branes, and synovial fluid. From the enlarged joints these concretions 
may infiltrate overlying tissues and become subcutaneous, when they 
constitute the chalk stones, or tophi. These hard masses may become as 
large as walnuts or small oranges. They may perforate the skin and dis- 
charge a purulent material containing myriads of fine crystals of sodium 
biurate and develop into indolent ulcers. 

The synovial fluid becomes thick and scanty, or there may be a small 
effusion of fluid into the cavity of the joint. Later there may be erosions of 
articular surfaces, and thickening of the ends of the bones. 

The joints most frequently affected are the metatarsophalangeal joints 
of the great toes and most often only these; then may follow the ankles, 
knees, hands, and wrists. The elbows, shoulders, and hips are more rarely 
involved. Most rarely are the sternoclavicular, intervetebral, temporo- 
maxillary, and laryngeal articulations. 

643 



644 



DISEASES DUE TO FAULTY METABOLISM 



The gouty deposits are also frequent upon the cartilage rims of the ear, 
tendons, various aponeuroses, the skin of the palm of the hand or soles of 
the feet, eyelids, nose, and other parts of the face. More rarely they occur 
upon the vocal cords, the cranial and spinal dura mater, the pia mater, the 
sclerotic coat of the eye, the fibrous sheaths of nerve trunks, and the aortic 
valves. 

A peculiar interstitial nephritis, with atrophy, is so often associated with 
this disease as to have received the name of "gouty kidney," or the "gouty 
form of Bright's disease." The peculiar feature of this nephritis is that 
sometimes uratic deposits are found in the kidney parenchyma. This latter 
condition seems more often to exist among the poor in hospital cases. In 
most cases renal disease is a sequence of gouty paroxysms, but in some 
it may precede or arise with the arthritic symptoms. In the well-to-do a 
marked gouty diathesis may exist with apparently no change in the kidneys. 

An endarteritis of gouty origin is doubtless the cause of many of the 
obscure circulatory and nervous symptoms of irregular gout. 

^Etiology. — The important underlying factor in gout is probably intes- 
tinal autointoxication brought about by faulty secretion of one or more of 
the glandular organs connected with the digestive tract, accompanied by 
the production of irritating poisonous substances which interfere with 
normal metabolism. 

Intrinsic Causes. — Age. — Most frequently middle aged people and 
people advancing in years have gout. The typical attacks come oftenest 
between the ages of thirty-five and fifty. If there is a strong hereditary 
taint, it may come earlier. Young men and boys at school exceptionally 
have gout. Or the first attack may come in old age. 

Sex. — It is rare in women, which is probably due to dietetic differences. 
It is said that the catamenial discharges protect women to a certain extent. 
After the menopause, irregular gout is not uncommon. 

Heredity. — Gout runs in families. Three fourths of the cases can be 
traced to a gouty ancestry. Women of gouty families may escape, but 
the transmission through females is more certain than through males. 

Bodily Conformation and Individual Pecidiarities. — A large frame and 
a vigorous appetite, with a tendency to corpulence, may be said to predis- 
pose to gout. Dietetic factors and a sedentary life added to these easily 
favor the invasion. 

Extrinsic Causes. — Errors of Eating and Drinking. — "Gout is the 
Nemesis of high living." The ingestion of more food than can be oxidized, 
and the presence of those conditions in the body which prevent the 
working up and assimilation of even a moderate supply of food, are 
causes of gout. Highly nitrogenized articles help to the excessive forma- 
tion of uric acid and favor the accumulation of urates in the blood. 
Food of animal origin is richer in nitrogen than that from vegetables, 
and the prevalence of gout among people who eat meat three times a day 
is in direct contrast to its prevalence among those who have it but once a 
day or three times a week. 

Alcoholic beverages more than anything else are most provocative of 
gout. There is quite a difference, however, in the potency of these different 
alcoholic beverages. 



GOUT 



645 



Port, sherry, madeira, burgundy, champagne, strong ales, porter, and 
stout are much more powerful factors in producing gout than the distilled 
spirits. 

Occupations, such as those of butlers, gentlemen's servants, butchers, 
inn keepers, brewers' drivers, and cellarmen, conduce to gout. Drunkards 
and topers rarely acquire gout, so that it seems as if the use of alcohol com- 
bined with highly nitrogenous foods were more conducive to gout than the 
one or the other alone. 

Habits of Life. — Those who lead an out of door life and have sufficient 
exercise can carry on a scale of eating which would involve those of sedentary 
habits in the penalties of gout. 

Saturnism in its relation to gout has been much discussed, and it seems 
that only those persons who have either an hereditary or an acquired pre- 
disposition to gout can have an attack brought about by lead poisoning. 

Immediate Causes of an Attack of Gout. — They are often undis- 
coverable, and the attack may occur unexpectedly in the midst of apparent 
health. 

Spring and autumn are the favorable times for paroxysms. At times 
some incident or circumstance, such as an unnatural excess of luxurious 
living, indulgence in rich wines, special worry, anxiety, a fit of anger, a 
studious effort, exposure to cold, or an accidental injury to a member or joint, 
may seem to be an exciting cause. However, none of these could bring 
the attack about were not the disease latent in the system. 

Symptoms. — Acute Gout. — The attack is apt to come on during the 
night or early morning, and there is sudden pain in one of the great toe 
joints, with chilliness, fever, restlessness, and sleeplessness. The next day 
the joint is swollen and the skin is red, tense, and shining. The joint is 
extremely tender and painful. The urine is scanty, high colored, and acid. 
Such an attack may last for a few days or for weeks. 

The first attack is usually without prodromes, but the subsequent 
attacks and sometimes the first one are preceded by indigestion, constipa- 
tion, palpitation of the heart, bronchitis, dragging muscular pains, irritabil- 
ity of temper, and depression of spirits. The urine is scanty and high 
colored or abundant and pale. There is a brick dust sediment of urates. 
There may be a trace of albumin, and the uric acid is below normal in 
amount before and during a paroxysm, but after the attack it is increased 
in amount. 

After the inflammation has subsided, the joint returns to its natural 
condition or may be left a little stiff. The skin undergoes desquamation. 
The intensity of the inflammation of the joint varies very much in the 
different cases. The height of the temperature varies usually in proportion 
to the severity of the joint lesion, and the recovery from the first attack 
is usually speedy and complete, so that the patient often feels better than 
before the attack. 

There is often an interval of one, two, or even three years before another 
attack, and the frequency of recurrence is greater as time goes on, until they 
recur once or twice a year. Then a large number of joints become involved. 
The attacks become subacute, and soon the condition of chronic gout is 
entered upon. 



646 



DISEASES DUE TO FAULTY METABOLISM 



Chronic Gout. — The recovery from the paroxysms is less complete, the 
attacks are of longer duration, and recurrence is more frequent. Some 
joints may become permanently stiffened and deformed, and tophi make 
their appearance about the knuckles, toes, knees, and elbows. It proceeds 
thus only occasionally, for by a change in habits and diet the course is 
arrested and mitigated. Frequently as years advance one who has in 
middle age suffered greatly from gout may subjugate or entirely cure it. 
The urine in chronic gout is copious, of low density, and paler than normal. 
In about one half of all cases there is a small amount of albumin. It is 
usual to observe a diminution of uric acid. There is no diminution in the 
amount of urea excreted. Sometimes there is a tendency to the formation 
of uric acid gravel, and arthritic attacks seem to alternate with attacks of 
renal colic followed by the passing of uric acid calculi. 

The blood serum is impregnated with urates, but a similar condition 
exists in leucaemia, pneumonia, anaemia, and Bright's disease. 

Irregular, or Visceral, Gout. — One is said to have irregular gout 
when he has the gouty diathesis and is suffering from one or more of the 
associated phenomena. These phenomena are most varied in character 
and may implicate any function or system of the body. They may be 
premonitory of an attack or may come and go without any arthritic seizure; 
or they may occur in persons who have never had any arthritic seizures. 
The diagnosis is made usually by the family history and by exclusion of 
other causes. 

Gout Affecting the Circulatory System. — Palpitation of the heart, 
with a faltering, interrupted pulse and syncopal threatenings, are not in- 
frequent. A very peculiar paroxysmal disturbance of circulation is now 
and then witnessed in which the cardiac pulsations become extremely rapid 
and a condition is produced which is termed "runaway heart." Such 
paroxysms are very alarming. There may be a simulation of angina pectoris, 
and it may constitute a "false angina," symptomatically indistinguishable 
from the true angina. Great care must be made in the differential diag- 
nosis. There is no connection between gout and endocarditis and peri- 
carditis except by reason of changes in the blood vessels. When the kidneys 
become involved, increased arterial tension will damage the circulation. 

Thrombosis of Veins. — The gouty diathesis seems provocative of the 
formation of clots in the veins, usually in the upper or lower extremities. 

The respiratory organs not infrequently feel the influence of the gouty 
diathesis. Asthma, pleurisy, emphysema, bronchitis, and pneumonia are 
among the disorders observed. 

Cirrhosis of the liver has been repeatedly found. 

The gouty kidney is a chronic interstitial nephritis with atrophy, which 
shows its regular symptoms. 

Gouty Affections of the Nervous System. — Recurrent headaches, 
persistent depression of spirits, and various forms of neuralgia and neuritis 
are frequent in irregular gout. Sciatica is one of the commonest of the 
forms of neuritis. Facial neuralgia is exceedingly troublesome, interfering 
with the ingestion and mastication of food. Neuralgic pains may affect the 
viscera and shift irregularly from place to place. Nervous disturbances 
may assume a more serious form and go on to delirium. 



GOUT 



647 



Vertigo, cephalalgia, insomnia, nervousness, tinnitus aurium, 
paresthesias, muscular cramps and twitchings, and vasomotor dis- 
turbances are among the more indefinite nervous phenomena attributed to 
the gouty diathesis, also epileptoid seizures and insanity. 

Gouty Affections of the Skin. — Eczema is the most distinctive, and 
the most frequent situations are the external ear and neighboring parts, 
the face, forehead, and back of the neck. As a rule, it is not severe, but 
persistent, and confined to the parts mentioned, but occasionally it becomes 
grave in persons advanced in years, and spreads over a large part of the 
body. 

Psoriasis in patches, like a dry, scaly eczema, fixed, circumscribed, and 
often unsymmetrical in position, sometimes appears on the legs and else- 
where. 

Pruritus, local or diffused, is not uncommon, and occasionally is 
troublesome, particularly at night. 

The nails may become brittle and ribbed, making it difficult to trim them. 

Gouty Affections of the Eye. — Conjunctivitis and sclerotitis are the 
most common of these unusual features of irregular gout. Gouty iritis 
and glaucoma have been described. Hemorrhagic retinitis in connection 
with gout has been observed. It comes on suddenly and is always unilateral, 
probably being caused by thrombosis of a retinal vein. 

Retrocedent Gout. — The inflammation in a joint may subside sud- 
denly from an unknown cause or apparently the application of cold to the 
joint. 

Differential Diagnosis. — Gout is liable to be confounded with rheumatism, 
acute and chronic, and arthritis deformans, more rarely with a gonorrhceal 
or pyemic joint or traumatic arthritis. As a rule the diagnosis is easy, but 
exceptionally we find it difficult. Gouty inflammations are usually affirmed 
by finding uratic concretions in the rim of the ear or elsewhere. The gouty 
paroxysm is characteristic, and we get its history in later manifestations. 
The family history of gout yields important information, and of almost 
equal importance are the past mode of life and dietetic habits, particularly 
with regard to alcoholic beverages. 

Age and Sex. — Gout seldom attacks a person before his thirtieth or 
thirty-fifth year unless hereditary influence is very strong. Acute rheuma- 
tism, on the other hand, is more frequent between the ages of fourteen and 
thirty. The female sex is very markedly more exempt from gout than from 
rheumatism. 

Clinical Differences between Gout and Rheumatism. — 1. The fever of 
gout is not so high; the local pain is more severe; the larger joints (ex- 
cept the knees) are less generally implicated; there is an absence of car- 
diac complications; sweating is not nearly so conspicuous in gout as in 
rheumatism; when gout is subsiding, cedematous pitting is usually ob- 
served about the joints, followed by a desquamation of cuticle. This is 
not seen in rheumatism. 

2. In chronic and irregular gout the diagnostic difficulties are at times 
most embarrassing. The term rheumatic gout is no longer in favor, still in 
exceptional cases the two diseases may be combined, as a gouty person 
may have rheumatic fever as a separate infection. 
42 



648 



DISEASES DUE TO FAULTY METABOLISM 



3. From arthritis deformans we distinguish gout as follows: 



Gout 



Arthritis Deformans 

Commonest in women. 
Disease of older people. 
Often poorly nourished people. 
Pain upon motion. 
Gradual onset. 
Often symmetrical. 
This joint often affected. 



8. 
9. 



1. 

2. 
3. 
4. 
5. 
6. 
7. 



More common in men. 

Middle age disease. 

Well nourished individuals. 

Pain is spontaneous. 

Rapid onset. 

Not symmetrical. 

Temporomaxillary joint seldom 

attacked. 
Decreased diet improves trouble. 
Tophi characteristic. 



Increased diet improves. 
None. 



Rheumatism may predispose to arthritis deformans, and the latter may 
be associated with gout. 

A gonorrhceal joint is associated with a history of gonorrhoea. 

A pyemic joint is accompanied by infection in some other part of the 
body and by a septic temperature curve. 

A traumatic arthritis involves a history of injury. 

The prognosis depends upon the complications. However favorable 
it may be for the first attacks, permanent release from the disease is rarely 
to be hoped for unless the strictest hygiene and dietetic rules are followed 
for the rest of life. With the most careful observance of all these prophy- 
lactic and dietetic measures of treatment, future attacks will be rare or 
comparatively mild and may cease, and severe lesions of internal organs 
will not occur. 

If the kidneys remain sound, and the periodical attacks are not too 
frequent and too protracted, the general level of health is not appreciably 
lowered. 

Albumin in the urine is an untoward sign, but gouty persons may have 
traces of albumin in the urine for many years, even to old age. 

With disease of the kidneys, the heart becomes affected, and sooner or 
later compensation fails, with consequent adema, dyspnaa, debility, and 
emaciation. A speedy end may be brought about by ur&mia, cerebral 
hcemorrhage, or embolism. 

Treatment. — Prophylaxis. — Temperance and hygienic living in all 
people, particularly in those who are the offspring of gouty parents, is the 
best protection. An active out of door life, with systematic exercise in the 
open air, as by walking, riding, or driving, golf, or tennis, is essential. 
Heavy dinners and late hours should, as far as possible, be avoided, as well 
as anxious and worrying engagements and undue mental and bodily fatigue. 
The action of the skin must be kept in order by means of baths and friction. 
As gouty people are generally neurotic, idleness should not be encouraged. 
A glass or two of hot water before going to bed and upon rising tend to carry 
off waste products. 

Di 

ET - — As has been seen, the habit of overeating and drinking, the in- 
dulgence in meats, heavy, sweet wines, and malted liquors, directly pre- 
disposes to the gouty diathesis. A moderate amount of meat once a day 



GOUT 



649 



and great temperance in alcoholic beverages must be insisted upon. An 
abundance of rich food must be avoided, and the watchword is plain 
living. A change to a vegetarian diet may be called for. 

In an attack of gout the bowels should be relieved at the outset by 
a suitable purge. 

1$ Podophyllin gr. 3; 

Calomel, gr. x; 

Pulv. aromatic, gr. v. 

M. 

The skin also should be made to act. If there is high fever the patient 
should be put to bed upon a diet of milk, farinaceous foods, and freely 
administered diluents. Water and peppermint water are excellent drinks. 
Alcohol should be withheld except in old, feeble people who may have a 
little spirits, and whose diet must not be too meagre. There should be no 
bleeding, no leeching; they are not necessary, and the application of cold 
to the joint seems not to relieve pain. The joint should be at rest, swathed 
with cotton and covered with an impervious protective, which acts as a 
poultice, promotes transpiration, and relieves pain. 

For the relief of pain we employ the usual narcotics and sedatives, such 
as morphine subcutaneously, chloral and bromide, phenacetin, and acetan- 
ilide. Iodide of potassium and salicylate of sodium may be given in fairly 
large doses. Such drugs are to be taken two or three times a day in combi- 
nation with 10 to 25 drops of the wine of colchicum. As soon as active 
inflammation subsides, the use of these drugs is to be discontinued and a 
regimen adopted which will diminish or overcome intestinal toxcemia, viz.: 
Plain mixed diet, one third less meat. Abundance of water (mineral water 
not essential). Ten drops of dilute hydrochloric acid, in water, after eating. 
A teaspoonful Carlsbad salt in the morning, in warm water. One aloin pill 
at bedtime. Exercise, warm baths, and general massage. 

The treatment of chronic and irregular gout is carried out on the 
same lines. It consists principally in diet and regimen. The proteids in 
food furnish uric acid, and although they exist in vegetables, the foods of 
animal origin contain a much higher percentage. Fat, starch, and sugar 
have no direct influence in the production of uric acid, and their free con- 
sumption lessens the amount of nitrogenous food taken and indirectly 
diminishes the production of uric acid. 

TABLE SHOWING AVERAGE PERCENTAGE OP ALBUMINOID MATTERS 
CONTAINED IN DIVERSE ARTICLES OF FOOD 



Animal food. 



Albuminoid 
matter. 



Vegetable food. 



Albuminoid 
matter. 



Butcher's meat 

Fowl 

Game 

Fish 

Egg 

Milk 

Cheese 



19 
20 
22 
17 
13 
4 
30 



per cent. 



Bread 

Oatmeal 

Rice 

Green peas 

Potatoes 

Carrots and turnips 

Green vegetables and salads 
Fresh fruits (excluding nuts) 



8 per cent 



12 
6 
6 
2 
1-2 
1-2 
4-1 



650 



DISEASES DUE TO FAULTY METABOLISM 



Gouty people should partake cautiously of meat, fowl, game, and cheese, 
and as freely as their digestion will permit of bread, rice, garden vegetables, 
salads, and fruit. Diet is of such importance that a change in diet may 
make all the difference between the occurrence and non-occurrence of an 
arthritic attack. 

Hydrochloric acid, Mx, t. i. d., in water after meals is highly important 
in overcoming intestinal putrefaction. 

Certain alcoholic beverages play a very important part in the genesis of 
a gouty constitution. How it takes place is not known, but it is known that 
they produce no appreciable amount of uric acid. Distilled spirits have but 
little influence in producing gout, and whiskey and gin less than brandy. 
On the other hand, the richer wines, port, sherry, madeira, champagne, 
burgundy, and strong ales and stout are highly provocative of gouty mani- 
festations. Most wholesome for the gouty are clarets and the light German 
wines. Fully fermented and mature dry wines are less injurious than sweet 
and new wines. For a robust gouty individual total abstinence is best, 
but some persons fare better with a moderate allowance of alcoholic liquors 
than without any, as abstinence may favor the development of a low, 
asthenic type of gout, manifestly more injurious to the general health than 
frank inflammatory attacks. 

Mineral Springs. — Those containing sodium salts are probably pro- 
vocative of harm rather than good. Among those which contain no sodium 
or only a trace, there are in England Buxton and Bath; in Germany Wild- 
bad, Neuenahr, Teplitz, Ems, and the Sauerling Spring at Carlsbad, in 
Austria; in France Aix-les-Bains, Contrexeville, Vichy, and Barege; in the 
United States the waters of Saratoga, Bedford, and the White Sulphur 
Springs. No doubt the effect of these springs is due to their watery con- 
stituents rather than the minerals which they contain. In the quantities 
in which they are taken, and upon an empty stomach, they dilute the blood 
and help the kidneys in elimination. 

Local Treatment of Gouty Affections. — Thickening, stiffness, and 
aching often persist long after an attack has passed away. Painting the 
joints with iodine, wet compresses, friction with stimulant liniments, 
shampooing with passive motion, and the application of flying blisters, all 
seem to help. Hot mineral baths, douches, and galvanic baths have been 
used with success, also vibratory massage. 

It is undesirable to remove the subcutaneous tophi, as the indolent 
ulcers remaining are very difficult to heal. If ulcers form, they are treated 
like ulcers of other origin, although their immersion in water for long periods, 
with the view of dissolving out the urates, has been most efficient. 

As the affections of the skin seem oftentimes to act as a safety valve to 
the general system, it is desirable not to interfere too actively with them. 
The itching and the irritation may be so bad as to interfere with sleep, and 
in such cases solution of borax with glycerine, boric acid with vaseline, lead 
lotion, zinc ointment, and bismuth and starch powder, applied to patches 
of gouty psoriasis, eczema, or prurigo, often afford great relief. The 
intense itching of the dry eruptions may be diminished by rubbing hard 
paraffin over the surface, which leaves a thin layer of paraffin. 



GLYCOSURIA AND DIABETES MELLITUS 



651 



GLYCOSURIA AND DIABETES MELLITUS 

In the present state of our knowledge it is impossible to give a clear 
definition of the enigma diabetes, and it is not always possible to make 
a good clinical distinction between an occasional glycosuria and the serious 
illness diabetes. 

The blood contains sugar (0.1 to 0.2 per cent) derived from the liver 
in the form of grape sugar, lsevulose, and pentose. Various organs, par- 
ticularly the muscles, use up sugar. A superabundance of sugar, which 
cannot be utilized by the muscles and organs, is carried off by the kidneys. 
A superabundance of sugar may probably enter the circulation through 
the gastroenteric tract directly without passing through the liver, and 
thus give rise to what is known as alimentary glycosuria. 

Transient glycosuria is observed following the administration of certain 
drugs, such as phloridzin, morphine, curare, chloroform, mercury, hydro- 
cyanic acid, and nitrite of amyl, and often poisoning by carbon 
dioxide. It also occurs with certain infections, such as malignant pustule, 
cholera, typhus or typhoid fever, scarlet fever, diphtheria, and malaria. 
It occurs after shock, injuries, concussion of the brain, fracture of the skull, 
cerebral haemorrhage, cerebrospinal meningitis, epileptic fits, anaesthesia, 
and experimental injury to the floor of the fourth ventricle. Glycosuria 
may therefore be of alimentary, hepatic, pancreatic, or central origin, etc. 
In the diabetic patient sugar is found in the urine on a proteid diet. 
In some diabetic individuals the urine becomes free from sugar whenever 
the carbohydrates in the food are below the limit of assimilation; in others 
the sugar disappears only when all saccharine and amylaceous food is 
stopped. These are the milder forms of diabetes. In the severe forms a 
strict meat and fat diet will not eliminate the sugar, which is probably 
formed from albumin. In some cases of severity, adiposity and goutiness 
are associated. It has been shown experimentally that extirpation of the 
pancreas in animals results in severe glycosuria, and some of our older 
pathologists report pancreatic disease in diabetes. On the other hand, 
numerous autopsies have shown a normal pancreas in diabetic subjects. 
The liver appears to play an important role in the pathology of diabetes. 
The excessive formation of organic acids and their acid products, acetone 
and /3-oxybutyric acid, as found in the urine, appear to have some influ- 
ence in the production of diabetic coma. 

In all probability chronic glycosuria or diabetes is a complex disease 
of faulty internal secretion (including the glandular apparatus of the 
intestine), and the exciting causes may be traumatism, infection, or in- 
toxication with subsequent organic changes in one or more of the affected 
organs. 

etiology. — Predisposing Causes. — Heredity. — Cases are on record in 
which many members of the same family have been afflicted with the dis- 
ease. Some diabetics have had family histories of gout, insanity, and 
phthisis. Hebrews are more commonly affected with diabetes than others 
of the community in which they dwell. 

Sex. — Men are oftener affected than women, the proportion being about 
three to two. 



652 



DISEASES DUE TO FAULTY METABOLISM 



Age. — The fifth decade seems to be that in which we see the largest 
number of cases, although children and extremely old people may rarely 
be affected. 

Temperament. — People of a neurotic tendency seem more likely to 
have the disease, the people of the older families and the more highly 
civilized. Thus, the older people of the older countries, as of India, Ceylon, 
and Italy, seem more prone to the disease than those of the more newly 
civilized countries. Thus the Hebrews, representing a highly intellectual 
class, a race given to a sedentary existence and often to high living, are 
more likely to have this disease than any other race. 

Obesity has been mentioned as a cause, but its relation to diabetes is 
obscure. 

Gout, syphilis, and malaria have been considered predisposing factors. 
The fact that a number of instances are on record where man and wife 
have had the disease one after the other makes us think of a contagious 
element (diabete a deux). 

Exciting Causes. — Mental Shock. — Severe nervous strain and worry, 
emotional disturbances, excessive sexual indulgence, and the climacteric 
precede many cases. 

Injury to or disease of the cord or brain, particularly of the medulla, 
such as haemorrhage, new growths, sclerosis, tabes dorsalis, epilepsy, insanity, 
and Graves's disease, have also seemed to be exciting. factors. 

Bodily injuries, such as railroad accidents, probably through a derange- 
ment of the innervation of the liver, are also reputed causes. 

It follows infectious fevers, such as typhus, typhoid, diphtheria, influenza, 
acute rheumatism, malaria, scarlatina, and cholera. 

Pregnancy has apparently given origin to some cases. 

Occasional cases have followed abscess of the liver, malignant disease 
in the abdomen not involving the pancreas, exposure to cold, iced food and 
drinks, and disease of the pancreas. 

Pathology. — The tissues after death from diabetes present as many 
pathological changes as are consistent, where nutrition is so seriously 
impaired, and may be regarded as due to failure in reparative processes. 

Blood. — The blood may contain as much as 0.4- per cent of sugar. 
There is also an excess of urea and fats. 

Circulatory System. — The heart is sometimes hypertrophied, may be 
fatty, and may be dilated. Dilatation of the heart is sometimes the cause 
of death. Endocarditis and arteriosclerosis are frequent and may result 
from irritation of the lining membrane by the sugar in the blood. Peri- 
carditis occurs occasionally. 

The Nervous System. — Brain. — The brain has been found in various 
inconstant pathological conditions, such as anaemia, cedema or atrophy of 
the cortex, and congestion and thickening of the meninges. More constant 
and important are the changes in the fourth ventricle, where tumors, cysts, 
softening, sclerosis, haemorrhage, and other changes have been found. 

The spinal cord may show extension of the morbid processes in the brain. 

Cerebrospinal Nerves. — Tumors pressing upon the organs and other irri- 
tations have been described. Peripheral neuritis is not uncommon. The 
sympathetic ganglia and nerves may be enlarged, hardened, or atrophied. 



GLYCOSURIA AND DIABETES MELLITUS 



653 



Lungs. — The lungs may show secondary changes: Bronchopneumonia, 
lobar pneumonia, abscesses, gangrene, tuberculous inflammations, pleurisy, 
and empyema. Congestion and oedema occur oftenest. 

Liver. — This organ may be fatty, in an inflammatory condition, or cir- 
rhotic. In a form of diabetes, diabete bronze, there is a peculiar pigmentary 
degeneration of the liver associated with pigmentation of the skin. 

The kidneys are usually fatty, and chronic nephritis is common. 

The spleen may be small, pale, and soft, or enlarged and congested. 
Tubercles have been found in its parenchyma. 

The pancreas has been studied in particular as to its relation to dia- 
betes, but to no definite conclusion, as stated in the introduction. It 
may be firm and atrophied, the seat of pigmentary cirrhosis or of cancer, 
cysts, or fat necrosis. Glycogen can usually be found in any of the tissues 
or organs. 

Symptoms and Diagnosis. — The symptoms begin insidiously, and the 
first things usually to attract attention are the unnatural thirst, the fre- 
quent urination of large amounts, and a voracious appetite. 

External Appearance. — We see usually wasting and emaciation, but 
well developed and even adipose diabetics are seen. The skin is harsh, 
and may show carbuncles or boils, or scars from them. It may be pigmented, 
diabete bronze. The hair is scanty and dry. 

The urine is usually pale, of a sweetish odor and taste, with a specific 
gravity usually from 1.025 to 1.045, exceptionally being lower or higher, 
and measuring in quantity from 6 to 8 pints in mild cases, to 30 to 40 pints 
in severe cases, in twenty-four hours. The specific gravity has been as 
low as 1.002. The reaction is acid. Sugar is present in various amounts, 
from ^ per cent up to 10 per cent in severe cases. One to two pounds 
may be excreted in twenty-four hours. In exceptional cases there is no 
polyuria. To establish the diagnosis of diabetes, the elimination of grape 
sugar must be constant and extend over a long period. 

The tests for sugar are given in the chapter on Laboratory Diagnosis. 
Glycogen is said to be found in diabetic urine. Albumin is present frequently. 
Gas may form in the bladder as the result of fermentation. Fat in the urine 
(lipuria) may exist. Urea and phosphates may be increased in amount, 
and acetone may be present. Polyuria is usually very marked. 

Symptoms Referable to the Digestive Organs. — Hunger and 
thirst may be excessive. Digestion is usually good, although constipation 
is common and temporary diarrhoea occasional. 

The tongue is usually dry, broad, and thick, with an irregular and fissured 
surface. It is sometimes coated and sometimes red. The gums may 
become spongy and bleed easily. The teeth tend to decay rapidly. Thrush 
may appear on the soft palate. Jaundice is frequently present. 

Constitutional Symptoms. — In the milder cases the general health 
remains unaffected for a long time. The body remains well nourished, and 
there is little discomfort except from the polyuria and polydipsia. In the 
severer cases the general health soon begins to show the drain. Emaciation, 
weakness, and exhaustion upon slight exertion are observed, and ultimately 
the marasmus may be extreme. The intellectual capacity is not impaired, 
although there is an indisposition to mental effort. Depression and ir- 



654 



DISEASES DUE TO FAULTY METABOLISM 



ritability are usual. The temperature is normal or subnormal. If there 
is fever, it is due to some complication. 

Complications. — The comjidi cations of diabetes are exceedingly nu- 
merous. 

Cutaneous Complications. — Furuncles, carbuncles, and suppurative 
processes following abrasions, injuries, or operations are frequent. Purpura 
is often present, and gangrene, especially of the feet, is apt to occur. The 
nails are dry and may atrophy or fall out. Herpes zoster and perforating 
ulcer are occasionally seen accompanying the disease. Profuse sweats may 
occur. 

Genitourinary Symptoms. — It is seldom that nephritis develops ex- 
cept late in the disease, and then come its symptoms. Albuminuria and 
ttdema are not infrequent. Sometimes the first symptoms are irritation and 
pruritus of the parts where moisture from the urine is likely to exist. In 
men there may be balanitis, inflammatory phimosis, or paraphimosis. Im- 
potence may be an early symptom. Cystitis is seen from time to time. 

Pulmonary Complications. — A fruity odor to the breath is the rule. 
Later in the disease pulmonary complications are very common, and nearly 
one half of the patients die of pneumonia, tuberculosis of the lungs, or gan- 
grene of the lung. 

Circulatory Symptoms. — The pulse and the heart are seldom affected 
until the disease is well advanced, when endarteritis and hypertrophy of the 
heart may develop. Dilatation of the heart may cause a fatal termination, 
as may also a fatty heart. 

Nervous Symptoms. — The nervous symptoms are very important. 

Diabetic coma is one of the most interesting and dreaded symptoms 
of this disease. It is more likely to occur in the young patients and in those 
in whom the disease advances rapidly and is associated with rapid emacia- 
tion. Before the onset of the coma the urine contains as much sugar as pre- 
viously, although the amount of urine may be diminished in quantity. 
Three forms are described: 

1. After an unusual bodily or mental exertion, the patient suddenly 
becomes prostrated, the heart's action grows rapid and feeble, the skin is 
cold, stupidity and a comatose condition supervene, and death occurs in a 
few hours. 

2. For a few days (from six to nine) the patient complains of weakness 
and gastric disturbances, nausea, loss of appetite, constipation, pain in the 
abdomen, drowsiness, and breathlessness. Some local affection, such as 
pharyngitis, a phlegmon, or a pulmonary complication, is present. Head- 
ache, restlessness, delirium, rapid and labored breathing, cyanosis, a feeble 
and rapid action of the heart develop, then stupor and coma come on, 
death occurring in from one to five days. 

3. Without previous dyspnoea or prostration, headache may develop 
suddenly, then vertigo, stupor, and coma, and death occurs in a few hours. 

Much discussion, theorizing, and painstaking investigation have been in 
progress for years as to the cause of this coma, but it now seems to be the 
almost universal opinion that it is due to acid intoxication and that the acid 
is /3-oxybutyric acid, which accumulates in the tissues, circulates in the 
blood in enormous quantities, and is eliminated in combination with other 



GLYCOSURIA AND DIABETES MELLITUS 



655 



elements. Temporary improvement and even cessation of the symptoms 
of impending coma are not impossible, but they are very exceptional. 

Peripheral Neuritis. — There may be mild neuritis in different parts 
of the body, giving rise to neuralgic pains, numbness, and tingling. Sciatic 
pains may be severe. 

Diabetic tabes is a name given to the association of severe neu- 
ritis with lightning pains in the legs, loss of tendon reflexes, paresis of 
the extensors of the feet, and the characteristic gait, which is called 
"steppage." 

Diabetic paraplegia is probably also due to neuritis. Cases are seen 
where both arms and legs have been paralyzed. 

Mental Symptoms. — Restlessness, headache, dizziness, anxiety, ner- 
vousness, and a tendency to melancholia are seen. Occasionally general 
paralysis develops. 

Special Senses. — Cataract, particularly in the younger patients, is 
common. 

Retinitis, hemorrhage into the retina, optic atrophy, sudden 
blindness, and paralysis of the ocular muscles have been observed. Otitis 
media at times seems to be diabetic in origin. 

Sexual Functions. — Impotence may be a common and early symptom. 

Abortion is likely to occur, if conception (which is rare) takes place. A 
diabetic mother may have a healthy child. Pregnancy and delivery ag- 
gravate the disease. 

Laryngitis and purunculosis of the larynx have been noted. 

Course and Prognosis. — In children the disease progresses very rapidly. 
Most children die within one year. As a rule, the older the patient when the 
disease begins, the more chronic is the course. The disease is more favor- 
able when the patient has no hereditary dyscrasia, when the disease is con- 
current with obesity and gout, when it begins late in life, when the social 
conditions are favorable and there is freedom from business and financial 
worry, and when treatment is begun early. The prognosis also depends 
upon the degree to which treatment is successful in reducing the amount of 
sugar. In cases supervening after an accident or acute disease the patients 
sometimes get well rapidly and sometimes slowly. In cases occurring at 
the climacteric in women the patients are more likely to recover than in 
any of the other cases. The state of the circulation, indicated by arterial 
pressure and cardiac impulse, is of great importance in the diagnosis. Com- 
plete recovery cannot be expected, but a large number of patients may 
enjoy fairly good health for a number of years. If it occurs in a person under 
forty years old, the outlook is bad. Death occurs from heart failure, diabetic 
coma, pulmonary affections, or nephritis. A few die exhausted and emaci- 
ated from the disease alone. The terminal stage of diabetes is that of 
ethyldiacetic acid poisoning. 

Treatment of Diabetes. — Hygiene. — Worry should be avoided. The life 
should be even and tranquil. A climate where there are the least changes 
of temperature is preferable. The skin should be kept in the best possible 
condition, so that excretion by this channel shall be unobstructed. A 
lukewarm bath, or a fairly cold bath if the patient can endure it, should be 
taken each day. An occasional Turkish bath is admissible. Exercise, not 



656 



DISEASES DUE TO FAULTY METABOLISM 



too violent, regularly for those who can endure it is important, and massage 
for those for whom exercise is impossible. Bowling is a good exercise. 

Diet. — After testing the amount of sugar in the urine for several days 
when the patient is on an ordinary diet, it is well to put him on a strict non- 
carbohydrate diet to see if the urine can thus be made free from sugar. Such 
a diet has been planned by von Noorden: 

Breakfast at 7.30 a.m. — 200 c.c. ( gvj) of tea or coffee, without milk 
or sugar; 150 gms. ( gv) of beefsteak, mutton chops without bone, or 
boiled ham; one or two eggs. 

Luncheon at 12.30 p.m. — 200 gms. ( 5vj) of cold roast beef; 60 gms. 
( 5ij) of celery, fresh cucumbers or tomatoes with vinegar, olive oil, pepper 
and salt to the taste; 20 c.c. ( 5v) of whiskey with 400 c.c. ( § xiii) of water; 
60 c.c. ( §ij) of coffee without milk or sugar. 

Dinner at 6 p.m. — 200 c.c. of clear bouillon; 250 gms. ( Svijss.) of roast 
beef; 10 gms. ( 3ijss.) of butter; 80 gms. ( gij) of green salad with 10 gms. of 
vinegar and 20 gms. of olive oil or three tablespoonfuls of some well cooked 
green vegetables; three sardines a 1'huile; 20 c.c. of whiskey with 400 c.c. 
of water. 

Supper at 9 p.m. — Two eggs, raw or cooked; 400 c.c. of water. 

In many cases the amount of sugar in the urine diminishes so rapidly 
that in three days none is found. If this is the case, we can gradually add 
sugar and starch until we see the sugar returning in the urine, and then 
keep just below the limit. Patients may return to this diet for a short 
period at intervals of three or four months. 

Diabetic patients may have the following articles of food: Liquids. — 
Soups: Ox tail, turtle, bouillon, and other clear soups. Lemonade, coffee, 
tea, chocolate, and cocoa; these to be taken without sugar, but saccharin 
may be used to sweeten them. Soda water, Apollinaris, Saratoga, Vichy, 
and milk in moderation may be used. 

Animal Food. — Fish of all sorts, including crabs, lobsters, and oysters; 
salt and fresh butchers' meat (excepting liver), poultry, and game. Eggs, 
yolk of eggs, cream, butter, buttermilk, curds, and cream cheese. 

Bread. — Gluten and brown bread, almond and cocoanut biscuits. 

Vegetables. — Lettuce, tomatoes, spinach, chicory, sorrel, radishes, 
asparagus, water cress, mustard and cress, cucumbers, celery, and endives. 
Pickles of various sorts. 

Fruits. — Lemons and oranges, currants, plums, cherries, pears, apples 
(tart), melons, raspberries, and strawberries may be taken in moderation. 
Nuts as a rule are allowable. To aid digestion, 5 drops of dilute hydrochloric 
acid should be taken after each meal, in water. 

Among prohibited articles are the following: Thick soups, liver, ordinary 
bread of all sorts (in quantity), rye, wheaten, brown or white. 

All farinaceous preparations, such as hominy, rice, tapioca, arrowroot, 
sago, and vermicelli. 

Potatoes, turnips, parsnips, squashes, vegetable marrows of all kinds, 
beets, corn, and artichokes. 

Liquids. — Beer, sparkling wine of all sorts, and the sweet aerated drinks. 



SPECIMEN DIET IN DIABETES 



657 



SPECIMEN DIET FOR ONE WEEK 

Supper. — One half doz. raw oysters, two lamb chops, lettuce, gluten 
bread and butter, cheese, and a cup of tea. 

Breakfast. — Two soft boiled eggs, gluten bread and butter, and a cup of 
coffee with cream. 

Dinner. — Bouillon and egg, a piece of steak, oyster plant, salad, gluten 
bread and butter, and claret wine. One half hour later, a cup of coffee. 

Supper. — Cold turkey, sardines, celery, a piece of cheese cake made with 
gluten flour and lsevulose, and a cup of tea. 

Breakfast. — Two soft boiled eggs, gluten bread and butter, and a cup of 
coffee with cream. 

Dinner. — Bouillon and egg, roast turkey, gluten bread dressing, celery, 
cranberries sweetened with lsevulose, Mosel wine, and a cup of coffee. 

Supper. — Turkey salad, celery, cheese, and a cup of tea. 

Breakfast. — Two soft boiled eggs, sardines with lemon juice, and a cup 
of coffee with cream. 

Dinner. — Bouillon and egg, a piece of steak, gluten bread and. butter, 
cheese, claret, and a cup of coffee. 

Supper. — One half dozen raw oysters, milk oyster stew, and tea. 

Lunch at 10.30 a.m. — Sauerkraut and pigs' knuckles, wine and seltzer. 

Breakfast. — One glass of milk and seltzer, two soft boiled eggs, and a 
cup of coffee with cream. 

Dinner. — Bouillon and egg, corned beef and cabbage, claret wine, a 
cup of coffee, and gluten bread and butter. 

Supper. — One boiled fish with butter sauce and celery, gluten bread and 
butter, and a cup of tea. 

Breakfast. — Ham and scrambled eggs and a cup of coffee with cream. 

Dinner. — Chicken fricassee, celery, spinach, bouillon and egg, a cup of 
coffee, and bread and cheese. 

Supper. — Smoked salmon, cervelat sausage, gluten bread and cheese, 
and a cup of tea. 

Breakfast. — Two soft boiled eggs and ham and coffee with cream. 

Dinner. — Bouillon and egg, beefsteak and salad, gluten bread and wine. 

Four p.m. — One dozen raw oysters. 

Supper. — Steak, celery, bread and butter, cheese, and a cup of tea. 

In order to avoid monotony, variety in soups, vegetables, flavoring and 
seasoning substances should be planned. 

Mechanotherapy in Diabetes. — All forms of exercise are beneficial 
in moderation. Vibratory massage over the stomach, liver, pancreas, or 
the entire abdomen and lumbar region should be employed. 

Electrotherapy. — The high frequency current or the static current 
should be tried. 

Inhalation. — Ozone inhalations through a static machine attachment 
or a house ozone generator are useful to combat secondary anaemia. Medic- 
inal and empirical treatment is unsatisfactory. 

Brewers' yeast is given in tablespoonful doses three times a day. Blue- 
berry leaves in decoction and powder form is a time honored household 



658 



DISEASES DUE TO FAULTY METABOLISM 



remedy. Tryptogen, which contains various digestive ferments in com- 
bination with gold and arsenic bromide, is given in five grain tablets three 
times daily. Desiccated glands which furnish internal secretion may be 
tried in rotation or combination. Improvement sometimes follows the ad- 
ministration of codeine, gr. ^ three times a day, up to gr. vj a day. Mor- 
phine, gr. I three times a day and upward, or phosphorus may be used. 
Vichy water with sodium bicarbonate added is the best drink, as alkalies 
counteract the tendency to coma. 

The coma which is so much dreaded should always be thought of as a 
possibility, and long railway journeys, sudden changes of diet, constipation, 
mental excitement, and worry should be avoided. In coma enteroclysis, 
with water at 110° F. containing 5j of bicarbonate of sodium to the pint, 
is indicated. 

Furuncles, carbuncles, and gangrene require surgical treatment. 

The increasing number of cases of diabete a deux reported in medical 
literature would indicate that it is not desirable that a diabetic and a non- 
diabetic person should share the same bed. 

OBESITY 

"The development of fat constitutes a disease when it interferes with 
the function of some organ or organs." 

^Etiology. — 1. Heredity. — In some families there are generations of fat 
people. These persons seem to grow more and more obese as they grow 
older, and the treatment is very unsatisfactory unless rigidly carried out. 
We must not, however, overestimate the hereditary tendency. 

2. Modes of Life. — Bad habits of life are probably the most important 
of all the causes. The habit of overeating, particularly of carbohydrates 
and fats combined with alcoholic beverages, especially beer, is most per- 
nicious. With this overeating, a lack of exercise, as is usual in a sedentary 
life, and oversleep prevent oxidation and fat accumulates. 

3. The sexual relations seem to offer a predisposition to fat accumula- 
tion. At puberty, at the menopause, and after atrophy or removal of the 
testes or ovaries we see individuals grow stout. 

4. Congenitally small lungs, making a defective oxygenating capacity, 
have also been mentioned as a cause. As people get adipose they are in- 
clined to be less active and to take less exercise on account of the difficulty 
in getting about, and the fat accumulates more rapidly. 

Pathology. — -We should distinguish between fatty degeneration and fatty 
infiltration, which is the condition we find in obesity. In fatty infiltra- 
tion, which is not necessarily a pathological condition, there is simply an 
excessive deposit of fat in the cells where normally fat is found. As this 
accumulates we observe the puffy cheeks, the pendulous breasts and ab- 
domen, the massive buttocks and thighs, and the coarse, greasy epithelium 
which are so unpleasant to see. Within the thorax and abdomen, about 
the heart and kidneys, and in the omentum this increase in fat may be 
enormous. Fatty degeneration is a term used to indicate the process of 
decay, a fatty breaking down of the albuminates within the tissue elements 
themselves. 



OBESITY 



659 



Symptoms. — There seem to be two forms of obesity, plethoric and 
anaemic. Plethoric obesity is more common in men, and seems the result 
of a general overnutrition. After the general infiltration of all parts of the 
body with fat, we ultimately observe hypertrophy of the heart and arterio- 
sclerosis. Then occur the derangements of circulation in different parts 
of the body, dropsy, cardiac asthma, cerebral hyperaemia, vertigo, tinnitus 
aurium, and throbbing of the arteries. A sudden increase of arterial pres- 
sure may cause rupture of a cerebral or meningeal vessel. 

Anaemic Obesity. — In this form we observe the symptoms of anaemia 
and those of obesity. It is more common in women and children, and the 
blood is always impoverished. Obesity may be extreme, and we note the 
fatty masses and the flabby, feeble, and ill developed muscles. The heart 
muscles also become flabby, and there is a small, feeble pulse from its 
diminished activity. There is a great incapacity for exertion, palpitation 
of the heart and dyspnoea resulting from the slightest exercise. These 
patients are more seriously ill than those who are obese from plethora. They 
are not gross feeders, nor always are they large drinkers. They usually 
prefer carbohydrate food, often having an aversion to animal food. This 
adiposity may be established before full growth, after menorrhagia, after 
severe haemorrhage from childbirth, and after severe exhausting illness or 
full mercurial courses. Dropsy is commonly associated with this form. 

Obese people are ill adapted to withstand any acute diseases, especially 
fevers. There is a progressive failure, unless a rigid and yet not too ex- 
hausting treatment is intelligently pursued. There ensue heart failure, 
bronchial catarrh, emphysema, gastroenteric catarrh, gastrectasis, fatty 
liver, greasy skin, comedones, greasy warts, eczema, erythema, and inter- 
trigo, furunculosis, and with a use of alcohol to excess we observe rosacea 
and hypertrophy of the nose. 

The causes of death may be cerebral apoplexy, cardiac failure, angina 
pectoris, or uraemia. 

Treatment. — The aim of all treatment is to prevent the ingestion of 
new supplies of fat and to promote oxidation. Some people do not get 
fat by forced feeding, and others do not get lean by underfeeding. There 
must be some factor influencing metabolism outside of lack of harmony 
between the quantity of food and spent energy. Perhaps the factor is 
suboxidation. 

Preventive. — Enforce habits of strict temperance in foods and drinks 
and an active life, both bodily and mentally. In hereditary tendencies, 
these principles must be insisted upon most rigidly. A seaside residence 
with sea bathing is an excellent preventive. 

Dietetic. — We may get remarkable results by regulating the diet. In 
general we withdraw a large part of the fat-producing articles. If we take 
away all of the fat and fat-producing food, the system suffers in various 
ways, so we allow small amounts. Fluids in large amounts should not be 
allowed, and the patient should be told to drink but very little at meals, 
reserving the time two hours after eating for the fluids. The "cures" 
established at Carlsbad, Marienbad, Kissingen, etc., depend, not alone 
upon the mineral water, but upon the diet and modes of life. The life of 
patients at such places can be much better arranged than it could be in their 



660 



DISEASES DUE TO FAULTY METABOLISM 



homes and during the management of their business affairs. In treating 
cases we first weigh the patient, then make a careful physical examination, 
noting the condition of the muscular walls of the heart, the state of the 
arteries, and the urine. Hereditary tendencies, habits, the plethora or 
anasmia, and the gouty or haemorrhagic proclivity must be considered. 
The presence of glucose in the urine and the output of urea, in addition to the 
foregoing, teach us in how radical a treatment we may indulge. The various 
systems of diet based upon the caloric demand for maintaining metabolic 
equilibrium are discussed in the chapter on Nutrition and Diet and in the 
article on the Fat Laden Heart in Obesity, to which the reader is referred. 

Many dietaries have been written and used in different cases, but the 
observant physician must make out a diet to suit his patient. The fol- 
lowing is a specimen: 

Six to eight ounces of hot or cold water half an hour before breakfast. 

Breakfast. — One to two ounces of toasted stale bread without butter, 
broiled white fish, mutton chop, beefsteak or cold chicken, game, beef 
tongue or lean ham. One or two small cups of tea or coffee with a little 
skimmed milk and no sugar. Saccharin may be used for sweetening. 

For weakly patients we may allow six ounces of bouillon or clear soup 
with a gluten or almond biscuit between breakfast and luncheon. 

Luncheon. — Cold meat, poached egg with spinach, lettuce, water cress, 
or other green vegetables, or a small omelette. A small amount of crust 
of bread or hard biscuit and a small amount of butter may be allowed. A 
glass of Bordeaux or Moselle wine (dry) may be taken with as much water. 
In the afternoon we may allow a cup of tea or a little skimmed milk and a 
gluten biscuit. 

Dinner. — No soup as a rule, although occasionally a little thin con- 
somme may be allowed. A little broiled or boiled fish, without starchy 
sauces, oysters or caviar, broiled or roasted meat, mutton, game, fowl 
with a very small portion of fat, green vegetables, no potatoes, and some 
stewed fruit flavored with saccharine or rendered less tart by adding half 
a teaspoonful of Rochelle salt. Two glasses of claret or a dry Moselle 
diluted with water may be allowed. 

Before going to bed, a cup of hot weak tea without milk, or as much hot 
water, should be taken. 

Regular exercise must be insisted upon — walking, riding, bicycle 
riding, or moderate gynasium work. The amount is to be regulated by 
the effect upon the heart. Oertel's system of exercise consists in climbing 
elevations, such as hills and mountains. 

The drinking of a glass of Kissingen water one hour after meals, and 
Vichy at the same time on alternate days, has, in addition to diet, been 
very beneficial in reducing fat. 

Thyreoid extract has been found to be highly beneficial in some cases, 
probably by assisting oxidation, but it is not yet known in which class of 
cases it can be used with impunity. The effects must be watched as care- 
fully as in myxoedema. The dose should be small to begin with, one grain, 
and if no bad effects are noted, it can be increased to five or seven grains 
three times a day. 



SCURVY, SCORBUTUS, IN ADULTS 



661 



SCURVY, SCORBUTUS, IN ADULTS 

Definition. — Scurvy may be looked upon as an acquired hsemorrhagic 
diathesis due to chronic ptomaine poisoning from intestinal putrefaction, 
causing mental depression, extreme debility, a tendency to syncope, and 
special lesions of the mouth, skin, and muscular system indicative of a 
morbid change in the composition and properties of the blood. Recent 
investigations prove that ptomaines derived from tainted animal food 
are potent factors in scurvy, or that it is due to an infection of the mouth 
with microorganisms. It is sometimes sporadic and sometimes epidemic 
or endemic in its occurrence. It was formerly prone to attack armies, the 
inhabitants of besieged cities, and especially seamen. To-day endemics 
are by no means infrequent, though much less extensive than formerly. 
They are most apt to occur in prisons or similar institutions and in barracks. 

Scurvy is due directly to a defective quality of food associated with 
privation. The want of fresh vegetable matter in the diet is not the prime 
factor, as was formerly supposed. 

The manifestations of scurvy, especially those of cachexia, may be much 
favored, though not directly caused, by conditions disturbing the main- 
tenance of good health and impairing physical vigor. Among such indirect 
causes are exhaustion by hard work, poor diet, previous disease, bad air and 
water, overcrowding, deprivation of sunlight, monotous diet, damp and 
unfavorable quarters, cold moisture, persistent heat, excessive muscular 
exertion, and an almost exclusive use of salt meat. 

On shipboard, debility from previous disease, especially from dysentery 
and malarial fever, often plays an important part. Sudden transition 
from heat to cold, or extreme cold, may bring on the first symptoms. 

Mortality. — The death rate, even in the very bad cases, may be remark- 
ably low, as the disease is wonderfully amenable to treatment. 

Cause of Death. — Death in syncope is not infrequent. It may result 
from extreme weakness, from preexistent disease, or from a complication 
with dysentery, malarial disease, progressive cachexia, pneumonia, peri- 
carditis, cerebral haemorrhage, or some other intercurrent disease. 

Night blindness seen in scurvy patients is believed to be due to exhaus- 
tion of the retina — a local symptom of the general debility. 

The pictures of the advanced and malignant cases most often occurring 
on ships, which we very seldom see nowadays, owing to our knowledge of 
its aetiology and methods of preventing it, are handed down both in medical 
works and in secular history. Nothing can be more disgusting, and although 
the treatment and prevention are very simple, it is a triumph in medicine 
that we have no more of this formerly unduly prevalent and loathsome 
disease, which through ignorance was attended with such high mortality. 

Symptoms and Diagnosis. — As a rule, the diagnosis is not difficult. 
The pulpy and swollen gums and the subcutaneous indurations are not 
characteristic of any other disease. Usually the symptoms are seen in a 
number of people living together, who have had insufficient diet and par- 
taken of tainted meat. The clinical phenomena regarded as characteristic 
of scurvy are the multiple lesions of the skin, gums, muscles, and bones and 
involvement of some of the viscera; the occasional sudden and brief attacks 



662 



DISEASES DUE TO FAULTY METABOLISM 



of fever followed by equally sudden and abundant effusion into the pleural 
cavity or the pericardium. 

Ordinary Mild Attack. — Scurvy comes on usually slowly and in- 
sidiously, the external lesions being preceded by extreme physical weakness 
and mental apathy, indicated by shortness of breath, a sense of thoracic 
oppression, fleeting pains in the back and lower limbs, and a peculiar 
sallowness of the skin. 

As the disease advances, the patient becomes listless and weary and the 
skin grows dry and rough and marked by small purple spots (petechia?), 
which are most abundant on the thighs and legs, sometimes being seen only 
on the lower extremities. Livid patches of varying size, resembling bruises, 
also appear. Subcutaneous swellings develop most frequently in the soft 
parts of the calf, in the ham, and behind the ankle. They are firm, widely 
diffused, not well defined, and very tender. The eyelids are slightly swollen 
and the conjunctivae often marked by bright red ecchymoses. Sometimes 
the lids become purple and swollen, and the conjunctiva appears "tumid 
and of a brilliant red throughout." 

The gums are soft and vascular, much swollen, and of a deep red color. 
The lips are anaemic and the tongue is moist and clean. A characteristic 
odor is noticed in the breath. There is dyspnoea upon exertion. The 
appetite is fair and the patient sleeps well. The urine is scanty and the 
bowels are constipated. 

The most characteristic symptom is the appearance of petechiae. They 
are smooth, level with the skin, persist under digital pressure, and consist 
of a circumscribed effusion of blood around a hair follicle. 

On board ship, particularly among colored men of the crew, it might 
be difficult to distinguish an outbreak of beriberi from one of sourvy. Many 
of its symptoms resemble those of scurvy. They both are cachectic dis- 
eases causing much muscular weakness; both give rise to severe muscular 
pains, dropsy in the lower extremities, breathlessness, and sudden death 
from syncope. 

Differential Points. — Beriberi presents in general no petechial spots 
or livid patches, but these are signs in colored people difficult to make out. 
However, in beriberi the gums are not swollen, the cedema usually begins in 
the front of the tibia instead of in the ankles, as in scurvy, and generally 
there are decided symptoms of peripheral neuritis, such as numbness and 
paresis of the limbs and tenderness along the course of the nerves. There 
is at first sight a strong resemblance between 'purpura, particularly Werl- 
hoff 's disease, and scurvy. 

Purpura is not due to any special defect in diet or relieved by an increased 
supply of antiscorbutics. It is characterized by plethora rather than anae- 
mia, and shows a marked tendency to epistaxis and bleeding from the 
internal organs; it affects chiefly the mucous membranes and the skin, 
while the muscles, bones, and subcutaneous soft parts remain free; there 
is no swelling of the gums, and the ecchymotic spots are more vivid and 
more generally diffused than those of scurvy. 

Haemophilia is a chronic affection of a congenital and hereditary nature, 
met with mostly in young people, and presenting haemorrhages from time 
to time, usually after some injury. 



SCURVY, SCORBUTUS, IN ADULTS 



663 



Leucocytelemia in rare instances presents a haemorrhagic swelling of 
the gums, but it shows glandular enlargements, a large spleen, and an excess 
of leucocytes in the blood, which scurvy does not. 

Pernicious Anaemia is more chronic in its course, its waxy pallor is 
quite different from the sallow hue in scurvy, and examination of the 
blood is convincing. 

Splenic Anaemia, a rare disease, differs from scurvy in being accompanied 
by a greatly enlarged spleen, a constantly elevated temperature, haemor- 
rhages usually of an oozing nature, sometimes profuse, and frequently 
epistaxis, but haemoptysis, haematemesis, haematuria, and haemorrhage 
from the bowel are rare. The petechiae which sometimes occur are very 
small and are most often seen in persons who are not confined to bed. 

Acute Ulcerative Endocarditis has its rapidly fatal advancement 
and its temperatures to distinguish it, although the petechiae and haemor- 
rhage may resemble those of scurvy. 

The prognosis is favorable if the attacks have not lasted long, if there 
are no visceral complications, and if antiscorbutics can be supplied at once 
and the patient placed in hygienic surroundings. Fluid in the pleural or 
pericardial sacs is of serious import, although it usually disappears rapidly 
with general treatment. Dysentery is a serious complication, and if not 
fatal much retards recovery. Care should be exercised not to give too 
favorable an opinion, as at any moment a moderate muscular exertion 
might produce fatal syncope. 

Prophylaxis. — A full and mixed diet. For adults on land this is seldom 
difficult to obtain, except in war. On long sea voyages it is particularly 
necessary to have preserved vegetables and fruits. Lime juice has been used 
for some years, but it has a tendency to deteriorate and become distasteful. 
Even though fruits and vegetables can be preserved so well nowadays, they 
are inferior to fresh products. 

An antiscorbutic list of foods contains fresh potatoes, cabbage, carrots, 
milk, malt liquors, light wines, tea, and cider. These beverages are re- 
markable for the large amount of potash they contain in combination with 
organic acids. Alcohol acts as an antiscorbutic in small amounts, and as a 
contingent cause of scurvy in large amounts. 

Other hygienic conditions must also be looked after; the meats should 
be fresh or well preserved; extremes of heat or cold are to be avoided; 
moderate exercise should be indulged in; and suitable clothing and good 
ventilation are necessary. All perishable food should be sterilized and kept 
in hermetically closed jars. Such precautions were taken by the Arctic 
explorer Nansen on his voyage in the Fram, as reported to the writer per- 
sonally by him. 

Treatment. — If no complications arise, the treatment is to simply supply 
the proper food, restore strength, and relieve the more severe local lesions. 
Proper diet will relieve even the severer symptoms, such as pleural and 
pericardial effusions. Care must be taken to avoid such articles of food as 
would intensify a complication, particularly dysentery, and to keep the 
patient in the recumbent position to prevent death from syncope. 

The diet should consist of a free supply of fresh vegetables (potatoes, 
green vegetables) with oranges and other succulent fruits and eggs, fresh 
43 



664 



DISEASES DUE TO FAULTY METABOLISM 



milk, strong soups, and beef tea; as the health improves and the digestive 
organs become stronger, chicken and lean meat may be added. Medicine 
is usually not necessary, but lime juice and lemon juice should be ad- 
ministered. 

Dysentery and diarrhoea require medication, and occasionally the effu- 
sions must be aspirated. The gums may be touched with solid lunar 
caustic or copper sulphate or washed with a 10 per cent solution of alum in 
water. The ulcerations should receive antiseptic treatment. The petechias 
gradually disappear, and the indurations, if persistent, may be treated by 
gentle massage or bandaging and compression. 

For scurvy in children, see the section on Paediatrics. 

DERANGEMENTS OF THE DUCTLESS GLANDS 

The pathology of the ductless glands embraces (1) functional and 
transitory disturbances, (2) inflammatory conditions due to infection, 
(3) the results of trauma, (4) parasitic invasion, and (5) tumor or cyst for- 
mation. As a result of faulty internal secretions, we observe various clinical 
manifestations due to faulty metabolism and catabolism. 

THE THYREOID GLAND 

The group of ailments depending upon diminution or absence of func- 
tional activity of the thyreoid gland may be best classified into: 1. Myx- 
cedema. 2. Sporadic and epidemic cretinism. 

Myxedema 

Myxcedema was first defined in 1873 by Sir William Gull as "a cretinoid 
state supervening in adult life in women." 

This disease with its characteristic features and symptoms is probably 
caused by the loss of function of the thyreoid gland. If the gland is con- 
genially absent, or the loss of its functions occurs before puberty, we call 
the disease cretinism. If the symptoms arise through operative removal 
of the gland, we call it operative myxcedema, or cachexia strumipriva. 

Symptoms. — It is more common in women, men contributing only 
about 10 per cent of the cases. There is such a similarity of appearance 
and symptoms among the patients with this disease that they look as if they 
belonged to the same family. There are symptoms which we see in every 
case, and a few accessory symptoms which we sometimes see in advanced 
cases. There is a marked general increase in weight, due partly to a firm 
thickening of the skin which is more than swelling and is unyielding to 
the touch. It does not pit upon pressure. It is very dry, in parts rough 
and scaly, and perspiration is absent or scanty. The swelling is not evenly 
distributed, there being a tendency to padlike formations in the supra- 
clavicular regions, in the axilla, and in other parts of the body. The eyelids 
are greatly thickened, as are the eyebrows, which overhang the orbits. Both 
lips are swollen and the base of the nose as well as the alee nasi are 
broadened. 

The face is pallid, except over the malar region, where there may be a 
faint pinkish blush. The character of the face is at once heavy and dull. 



MYXCEDEMA 



665 



The swelling and obliteration of the natural folds of the skin cause a lack 
of expression. The hair loses its natural gloss, becomes fragile, rough, and 
scanty, and falls out, leading almost to baldness. The ears may become 
very prominent. The hands, called "spadelike" by Gull, are broad, and the 
fingers are much flattened. Their movements are slow and awkward, and 
the tactile sensations are received slowly. 

The mucous membranes are similarly swollen. The teeth degenerate, 
decay, become loose, and fall out. The speech is so altered and character- 
istic that the diagnosis may be made by hearing a patient speak. The 
words come slowly and the voice is monotonous and of a "leathery timbre" 
and expressionless. This is due to the swollen condition of the throat and 
lips, and probably also to a nervous disturbance. The gait is typical of the 
disease. 

The mental condition is characterized by slowness in thought, percep- 
tion, and answers and by a poor memory. In the psychical symptoms we 
see a difference in the different patients. Some are exceedingly garrulous, 
much of their language being senseless and repetition. Some are taciturn. 
All are inclined to be irritable and suspicious, and exceptionally they are 
suspicious of self to such a degree as to lead to delusions, hallucinations, acute 
or chronic mania, dementia, or melancholia. Such patients must be watched. 
There may be abnormal subjective sensations, as of taste and smell, and 
there may be occipital pain. A marked change in temperament is occasion- 
ally observed, a peculiar persistence in ideas and deeds which no one can 
modify. Tremors and contractures of the hands and feet are sometimes seen. 
All the symptoms are ameliorated in warm weather and intensified by the 
cold. The patients are exceedingly susceptible to cold, and their tempera- 
ture is usually subnormal. The urine is ordinarily reduced in quantity, 
with no change in specific gravity. It contains, as a rule, no albumin or 
sugar, but the urea is slightly diminished. Menstruation is regular, but 
the amount of blood may be excessive. Pregnancy and parturition may 
take place after a woman has become affected with the disease, but haemor- 
rhage is to be dreaded. There is a tendency to haemorrhage apart from 
parturition, and the extraction of a tooth is quite often followed by con- 
siderable bleeding. 

Pathology. — The thyreoid gland may be absent, atrophied, or enlarged. 
If it is enlarged, the tissue is changed, either by a new growth or into fibrous 
tissue. Microscopically, the skin which is so swollen shows that the con- 
nective tissue is infiltrated with an almost transparent or faintly granular 
material. This change may be found in all parts of the body and organs. 

Prognosis. — Untreated myxcedematous patients, although they may 
live many years, gradually get worse and die of inanition, in coma, or with 
signs of bulbar affection. A few have died from cerebral haemorrhage. 
Tuberculous affections are among the most frequent of the intercurrent 
fatal diseases. A chronic nephritis may be the cause of death. 

Treatment. — The introduction of the thyreoid gland of the sheep into 
our materia medica has revolutionized the treatment of myxoedema, and 
if it is given before the disease is too far advanced, we effect cures, although 
most patients have to take it in small doses for the rest of their lives. We 
begin with small doses of the powdered gland, gr. iij or less, and increase 



666 



DISEASES DUE TO FAULTY METABOLISM 



to gr. xv or more a day. An overdose causes a rapid pulse and other symp- 
toms of poisoning. It is highly important that the patients should be kept 
warm. Winter should be passed in a warm climate if possible. Hot baths, 
friction, and massage may be of much good. Jaborandi or pilocarpine may 
be used to increase the action of the skin. 

Hypothyreoidism 

This term has been used to designate a group of symptoms associated, 
not with actual cessation of the thyreoid function, but with insufficient 
function or inhibition of glandular secretion. Such patients suffer from 
weak and rapid heart, persistent headache, and, if they are women, from 
menorrhagia. Obesity in children has in some instances apparently been 
due to thyreoid insufficiency. In both classes of cases the use of thyreoid 
extract has proved of decided benefit. 

Cretinism (Congenital Myxcedema; Myxedema of Childhood) 

This is a condition allied to myxoedema or identical with it, associated 
with imperfect development of the body and intellect, supposed to be due 
to absence of the thyreoid gland or lack of functional activity in that organ. 
There are two forms, the endemic and the sporadic. 

Endemic cretinism arises under local conditions, not understood, associ- 
ated with goitre. It is met with chiefly in Switzerland and parts of France 
and Italy. 

Sporadic Cretinism. — Various causes have been invoked for congenital 
absence of the thyreoid or for its failure to perform its function. Among 
these are consanguinity between parents, a family history of alcoholism, 
family tuberculosis or syphilitic disease, and mental shock and worry 
during pregnancy. There is sometimes a family history of deformities. 
The symptoms may develop after an acute fever. In the majority of cases 
we can discover no cause. 

Symptoms of Cretinism. — The symptoms usually appear during the first 
year, sometimes not until the children are two or three years old, and occa- 
sionally not before the eighth or ninth year. The appearance of cretins 
is most characteristic. The body may be so dwarfed as to give children 
of fifteen years the appearance of being two or three. The legs are bowed 
and the extremities, including the fingers and toes, are short and stumpy. 
The skin is thick and boggy, as in myxoedema. The head seems large for 
the body; the fontanelle closes very late, having been observed open in 
adult life; the forehead is low, the base of the nose is broad, the eyes are 
widely separated and set deep in a seeming furrow extending horizontally 
across the face; the lips are thick, the mouth gaping with the tongue pro- 
truding between two rows of carious teeth; the cheeks are baggy; the hair 
is coarse, straight, and usually light colored; and the teeth appear late and 
are apt to decay early. 

Fatty tumors of about the size of a hen's egg are frequently seen in the 
supraclavicular region, in the axilke, and in other parts of the body. The 
neck is short and thick, and in some cases there is a depression in the place 
where the thyreoid should be. The abdomen is large and pendulous, re- 



EXOPHTHALMIC GOtTRE 



667 



sembling the rhachitic abdomen. The voice is rough and hoarse. The 
skin is dry, perspiration is scanty, and eczema is frequently seen. The 
patients seldom walk until they are five or six years old, and then the gait 
is a clumsy waddle. They have a marked mental and physical torpor, 
being usually idiots. They learn to talk late, sometimes never learning. 
They are very sensitive to cold, as are the myxcedematous patients, and 
the temperature is usually subnormal. They are usually dull, placid, and 
good natured and seldom make trouble. Occasionally we see one who is 
vicious and has fits of ill temper and despondency. A cretin of fifteen or 
eighteen years may act like a child of two or three years. They suffer with 
chronic constipation, and the sexual instinct does not develop. 
There are three degrees of cretinism: 

1. Cretins manifesting only vegetative functions and deprived entirely 
of reproductive and intellectual faculties, including the power of speech. 

2. Semicretins, possessing the power of reproduction and some faculty 
of speech, the intellectual faculties being limited to perception of their 
corporeal wants. 

3. The "cretinous," having intellectual faculties superior to those of 
the semicretins and able in some degree to engage in trade and other em- 
ployments. 

Pathology. — The thyreoid gland may be entirely absent, there may be 
only a few fatty granules in its place, or it may have undergone cystic or 
fibrocystic degeneration. 

The diagnosis is usually easy when one has seen one case. We must 
distinguish cretinism from the various forms of idiocy that are not associated 
with thyreoid affections and from rickets and fcetal chondrodystrophy. 
The condition of the hair, skin, and teeth, the stunted growth, and the 
characteristic facies are usually sufficient diagnostic points. 

Treatment. — The treatment is the same as for myxoedema. The thyreoid 
powder is to be administered, beginning with gr. j three times a day, gradu- 
ally increasing according to need and toleration. If overdoses are given, 
symptoms of Graves's disease supervene. Usually the little patients 
become as well physically and mentally as their more fortunate contempo- 
raries, but occasionally, although the physical condition may reach normal, 
the mental state is unimproved. As soon as the normal condition is reached, 
the dose should be gradually diminished until the minimum dose that will 
prevent recurrence is known. Protection from the cold, baths, diaphoresis, 
etc., are aids as in myxcedema. Thyreoid grafting has not given favorable 
results. (See also Pediatric Section, page 227 and 228.) 

Basedow's Disease (Parry's Disease; Graves's Disease; Exophthalmic Goitre) 

It is a disease characterized by tachycardia (rapid action of the heart), 
enlarged thyreoid, exophthalmus, and muscular tremor. 

Etiology. — It is most common between the ages of sixteen and forty, 
and occurs in women more frequently than in men. In men the disease 
seems particularly well marked and more severe. It may run in families 
in which there is a neurotic tendency, and several successive generations 
may furnish one or more cases. Among the exciting causes we may note 



668 



DISEASES DUE TO FAULTY METABOLISM 



a fall, a blow, a fright or other severe mental shock, worry, intense grief, 
overfatigue, prolonged mental strain, and acute disease, such as influenza, 
quinsy, and rheumatism. It has followed epistaxis. It may occur after 
pregnancy. Anaemia may precede it, as may also menstrual disorders. It 
may be associated with epilepsy, chorea, hysteria, diabetes, or insanity. 

Pathology. — It would seem as if supersecretion of the thyreoid gland 
were at the bottom of the symptoms, as the administration of thyreoid 
extract in large doses to healthy individuals causes the same symptoms and 
from the fact that in myxoedema, where there is absence of the thyreoid, 
just the opposite symptoms are present. 

Symptoms. — There are cases which are developed rapidly and follow a 
rapid course. Much more frequently the development and course are 
gradual. Four symptoms are characteristic. 

Heart Symptoms. — Tachycardia is the first symptom developed, the 
most constant, and the most important. The pulse varies from 90 to 160 
and may be higher. The impulse against the chest wall is very notice- 
able to the patient and to the observer. The throbbing of the carotids 
is prominent, and there may be visible pulsation of the peripheral arteries. 
A capillary pulse is easily demonstrated. A well marked venous pulse is 
sometimes observed. Irregularity in the heart's action is a late symptom, 
and indicates a severe and serious condition. Murmurs at the apex and 
base are usual. The heart sounds may be so loud as to be heard at some 
distance from the patient. 

The GoiTRE. — The enlargement of the thyreoid in one lobe, or a 
general enlargement, is the next important symptom. It is usual, but not 
constant. At first it is soft, but gradually becomes harder. A thrill may 
be felt upon palpation, and a systolic bruit or venous hum may be heard upon 
auscultation. 

The exophthalmos is less constant than the preceding two symptoms, 
and develops later. There are different degrees of protrusion, and it is 
sometimes so marked as to give the characteristic staring, startled, fright- 
ened aspect. Occasionally the eyes protrude so much as to make voluntary 
closure of the eye impossible. The exophthalmus may be one sided, or 
uniocular. When the upper eyelid does not move downward synchro- 
nously with that of the other eye, we speak of von Graefe's sign. It is pres- 
ent in Basedow's disease, but it is also seen in other maladies. The term 
Stellwag's symptom is applied to an increased retraction of the upper lid 
into the palpebral fissure and the "diminished frequency and incomplete- 
ness of winking under reflex stimulation." It is usually present. 

Trembling. — There is a fairly constant muscular tremor, first affecting 
the hands and afterward becoming general. Excitement and the erect 
posture make it more prominent. The finer movements, as in writing 
or sewing, are impaired. 

Nervous symptoms are common. There may be hysteria, neurasthenia, 
irritability of temper, excitability, restlessness, and depression which may 
advance to melancholia. A temporary mania is occasionally seen. The 
normal temperament is often perverted, and the patient may become 
spiteful, suspicious, and untruthful. Neuralgic pains may be very annoying, 
and when they are precordial they simulate angina pectoris. In a few cases 



EXOPHTHALMIC GOITRE 



669 



the symptoms of general paresis have been observed. Headaches and in- 
somnia are usual. The digestive system is frequently disturbed. There 
are diarrhoea, flatulence, and vomiting, with pain simulating the gastric 
crises of locomotor ataxia. The appetite and thirst may be capricious. 

Flushes of the skin alternating with pallor may be very annoying. 
Pigmentation of the skin, as in Addison's disease, and leucodermic patches 
are sometimes seen. Sweating may be very profuse. Urticaria and angeio- 
neurotic oedema are common. There may be a slight rise of temperature, 
but it is exceptional. The subjective sensation of heat may be very marked. 

Menstruation is likely to be irregular; amenorrhcea, menorrhagia, and 
leucorrhcea are frequent. Emaciation may be extreme, but it is proportional 
usually to the severity of the disease, as is the loss of strength. Dyspnoea 
in attacks may be very severe. It is supposed to be caused by a sudden 
increase of pressure of the goitre against the trachea. 

Death may occur from the malady itself or from intercurrent disease. 
Sudden death from syncope or circulatory failure may take place even in 
a patient whom we think is doing well. They may die in marasmus with 
preceding great emaciation and prostration. Persistent vomiting, diarrhoea 
and dyspnoea may usher in the termination. In about half the fatal cases 
intercurrent disease is the cause of death. The commonest of such diseases 
are pneumonia and bronchitis. 

Treatment. — Hygienic management for the nervous phenomena is most 
essential. Diet, exercise or massage, baths, a cool climate, and avoidance 
of all excitement, fright, or worry are to be prescribed. Many drugs have 
been tried, generally with poor results. The anaemia should be treated 
with iron, which, in combination with digitalis, frequently seems to do good. 
Strophanthus and various other drugs have been used to slow the heart's 
action, which is one of the indications for treatment. 

Aconite, veratrum viride, ergot, and belladonna have been recommended. 
The latter, which seems to have the weight of evidence as to its being the 
best drug, should be administered until dryness of the throat is produced. 
Small doses of opium have helped in some cases, and bromide of potassium 
in others. 

Protracted rest in bed, with an ice bag over the heart continuously by 
day and over the lower part of the neck and the manubrium, is to be advised 
in severe cases. Galvanic electricity, with the anode placed over the cervical 
spine and the cathode upon some of the peripheral nerves, is recommended. 
Enteroclysis and fresh air are most important factors in treatment. 

In the treatment of Graves's disease with the milk of goats from which 
the thyreoid gland has been removed, the theory is that these animals 
develop in their organism a substance which would neutralize the toxine 
in these patients. Encouraging results have been reported by a number 
of observers. 

Treatment with thyreoid serum (antithyreoidin, Merck) is still in its 
experimental stage, but should be tried. 

Surgical procedures seem to have given the greatest relief, but the 
danger from the anaesthetic and the frequency of death upon the table 
should be taken into consideration. One lobe of the gland has thus been 
removed, the arteries of the gland having been tied. 



670 



DISEASES DUE TO FAULTY METABOLISM 



Goitre and Malignant Tumor of the Thyreoid 

Goitre is a hypertrophic condition of the thyreoid gland. It occurs 
endemically and sporadically. Sporadic cases are common in this country. 
Endemic goitre in Europe is seen in the mountainous regions of Switzerland, 
France, and Italy; in this country, about the eastern end of Lake Ontario 
and in parts of Michigan. We do not know why the trouble should arise. 
We have the following varieties: 

1. The parenchymatous, in which the enlargement is general and the 
follicles contain a colloid material. 

2. The vascular, where the enlargement is due to increased vascularity 
and dilatation of the blood vessels without the formation of new gland 
tissue. This is the so called " pulsating goitre." 

3. The cystic, in which the substance of the gland is occupied by cysts. 
The wells of the cysts may undergo calcareous degeneration. 

The enlargement may be general, it may affect one lobe, or it may 
involve the isthmus alone. The symptoms are due to pressure upon the 
trachea or upon the veins or, as some say, upon the vagi. This latter has 
been supposed to be a cause of the sudden death which occasionally super- 
venes. The majority of goitres give no symptoms. 

Treatment. — It is alleged that endemic goitre may be avoided by boiling 
the drinking water. Change of locality has been followed by a cure. Many 
drugs have been recommended. Among them are iodine and other counter- 
irritants, potassium iodide, ergot, and the thyreoid extract. The treatment 
of goitre with distilled or rain water has been advocated by a number of 
observers, who report that goitre has yielded entirely to this remedial 
measure, and it may be regarded as certain that pure water has a good effect 
on the course of the disease. Operative treatment is indicated in severe 
cases with tumor formation, as also in malignant tumors of the thyreoid 
gland. 

THE SUPRARENAL GLAND 

Addison's Disease (Morbus Addisonii; Bronzed Disease) 

A fatal constitutional disease characterized by prostration, heart weak- 
ness, gastrointestinal symptoms, and pigmentation of the skin. 

Etiology. — It is more frequent in men than in women, and usually 
occurs between the twentieth and fortieth years. The most recent ob- 
servations indicate that the symptoms are due to a loss of function of the 
adrenals. Injuries, such as a blow upon the back or abdomen, have been 
followed by this disease, and caries of the vertebra? has preceded the attack. 
There are some who think that the disease is due to an irritation of the 
abdominal sympathetic nerves. 

Pathology. — The suprarenal glands may have a tuberculous fibro- 
caseous lesion, which is the commonest condition found; there may be simple 
absence of the adrenals or a chronic interstitial inflammation with con- 
traction; syphilitic disease or malignant disease may involve the capsule; 
blood may be extravasated into the capsule; there may be pressure or in- 
flammation involving the abdominal sympathetic plexus, with no lesion 
of the adrenals themselves. Degeneration of the semilunar ganglion with 



ADDISON'S DISEASE 



671 



pigmentation and a sclerosis of the nerves has been described. Enlarge- 
ment of the ganglia in cicatricial tissue around the adrenals also has been 
observed. The thymus has been found larger than usual and persistent in 
some cases. The spleen may be found enlarged. When a severe lesion, 
atrophy, or absence of the adrenals is found at autopsy, and there have been 
no symptoms of Addison's disease, we may conclude that there have been 
accessory glands which have supplied the necessary suprarenal secretion. 
Tuberculous lesions of the adrenals may be associated with tuberculous 
lesions in other parts of the body. 

Symptoms. — There are four important symptoms. 

1. Prostration. — About the first symptom noticed is the weakness 
and intense languor of both body and mind. Dulness, apathy, listnessness, 
and peevishness are always present and gradually become more marked. 

2. Heart Weakness. — The patient may have frequent attacks of 
syncope, which occasionally are fatal. The heart weakness and the resulting 
poor circulation seem to give the symptoms of cerebral anaemia. 

3. Gastrointestinal Symptoms. — The invasion of the disease may 
be accompanied with attacks of nausea and vomiting, spontaneous in char- 
acter, which may be persistent and become more and more severe. Re- 
traction of the abdomen, with pain, simulating peritonitis, has been observed 
later in the disease. Anorexia may be present to a marked degree. 
Diarrhoea is more frequent than constipation. The gastric symptoms are 
variable in different patients, and also vary throughout the course of the 
disease. They may be absent. 

4. Pigmentation op the Skin. — Usually the bronzing of the skin does 
not occur until after the constitutional symptoms have become pronounced, 
but occasionally it is the first symptom. This pigmentation, from a yellow 
to a deep brown, occurs first in the face and exposed parts of the body, 
where there is any irritation or where there is normally some pigmentation, 
as about the nipples or genitals. A scattered pigmentation occurs pri- 
marily, but the spots may enlarge, coalesce, and become diffuse, so that the 
patient resembles a mulatto. The mucous membranes also become dis- 
colored, and pigmentation scattered over serous membranes has been 
described. In addition to the above mentioned symptoms, there are usually 
pain and tenderness in the lumbar and epigastric regions. 

Course of the Disease. — The disease is usually of long duration, from 
one to ten years, but it is occasionally acute, with a fatal termination in 
a few months. If the bronzing of the skin is absent or very slight, the 
disease is more severe and the course more rapid. These acute, severe 
cases show great weakness, fever, vomiting, diarrhoea, and delirium. They 
may prove fatal in a few weeks. 

Diagnosis. — As we see pigmentation of the skin in quite a number of 
different affections, we cannot make the diagnosis from that alone. Faint- 
ing fits, nausea, and gastric attacks are important symptoms. The tuber- 
culin reaction, found in tuberculosis of the adrenals where no tuberculosis 
could possibly be suspected, may be an aid to diagnosis. 

Prognosis. — Recovery is practically unknown, although it is said that 
there are a few instances. There may be periods of improvement lasting 
for many months. 



672 



DISEASES DUE TO FAULTY METABOLISM 



Treatment. — The use of suprarenal extract is indicated in Addison's 
disease. Some cures have been reported. Some patients are not at all 
benefited. 

Dose. — The gland is usually given in tabloids, three a day. Each 
tabloid contains one grain of the dried extract, which corresponds to fifteen 
grains of the gland. 

The hygienic life and treatment of the symptoms accomplishes some- 
thing. If the prostration is profound, the patient should be kept in bed, 
or heart failure is likely to occur at any time, even early in the disease. 

For the anaemia, iron may be given in full doses. Bismuth may be given 
for the diarrhoea. As for the vomiting, alleviation may be obtained by 
the use of creosote, bismuth, hydrocyanic acid, codeine, ice, or champagne. 
Purgatives should be most cautiously used, so as to avoid an exhausting 
diarrhoea. The diet should be light and nutritious. 

DISEASES OF THE PITUITARY BODY 

Acromegaly 

This is a rare disease characterized by an abnormal growth of all of the 
tissues, particularly in the bones of the hands and feet. 

^Etiology. — The cause of the disease is unknown. It begins at about 
the age of twenty-five, rarely earlier, and has been known to show itself 
first in the fortieth year. 

Pathology. — In the recorded autopsies the pituitary body has been 
found diseased in each case, and in the majority it was hypertrophied or the 
seat of a tumor. The thyreoid gland has been found hypertrophied in half 
the cases, and the thymus has been persistent in some instances. 

Symptoms. — Without real deformity, there is a marked enlargement 
of the hands and feet, more marked in the hands, which are broad and thick 
— spadelike. The bones, muscles, subcutaneous tissiies, and skin are all 
hypertrophied. The whole head is considerably enlarged, particularly from 
before backward. The face is much deformed. The nose becomes en- 
larged in all its dimensions, and the nostrils are large and broad. The jaw 
bones enlarge more than the other bones of the head, the lower jaw, in par- 
ticular, causing its protrusion beyond the upper, and marked disfigurement 
results. The superciliary ridges are prominent, the lips are thickened, the 
lower lip protrudes and hangs down, and the tongue may be considerably 
hypertrophied. 

The spine usually presents a positive curve, so that the chin may rest 
on the thorax. 

The thorax is flattened from side to side and may impede chest breathing, 
forcing the respiratory movements to be chiefly abdominal. 

The skin is often warty and thickened, the pendulous parts being par- 
ticularly thick. The dry, harsh appearance of the skin in myxcedema is 
not present in acromegaly. The hair becomes coarse, long, and thick. The 
labia majora and clitoris may be especially hypertrophied. 

Sensory and vasomotor symptoms of varied character may be present. 
Headache is usually persistent. Pain in the eyeballs is common. Speech 



THE SPLEEN 



673 



is usually thick and slow. Blindness, loss of the senses of taste and smell, 
cessation of menstruation, and muscular weakness with excessive perspiration 
are common. 

Treatment. — The only treatment from which benefit has been derived 
has been the administration of the extract of the pituitary glands. Fol- 
lowing its administration, relief from the subjective symptoms has been 
observed, with a relapse when the treatment is withdrawn. 

THE SPLEEN 

General Remarks 

The "spleen dulness" is not a trustworthy landmark, and a trivial en- 
largement permits of no important conclusions in diagnosis. Enlargement 
should not be diagnosticated unless the spleen can be felt or an increased 
area of dulness made out. An exploratory puncture can be done without 
much difficulty by introducing the needle under aseptic precautions in 
the interspace between two ribs, directly over and into the splenic dulness. 

The spleen is in sympathy with all forms of blood infection, and may 
suffer from an extension of an inflammatory process of the neighborhood. 
It shows passive congestion, like the liver, in circulatory disturbances. It 
may be the seat of amyloid degeneration, tuberculosis, septic abscesses, in- 
farcts, gummata, and other tumors, such as echinococcus cysts, and is chroni- 
cally enlarged in chronic malarial disease and in splenomedullary leucaemia. 
To elicit the nature of the splenic enlargement, an exploratory incision may 
be necessary. Cases of primary splenomegaly of unknown origin are re- 
ported. 

If we find a tumor below the left margin of the thorax, oval, notched, 
moving with respiration, and lying in front of the colon, it is the enlarged 
spleen. Over the kidney there is tympanitic intestinal resonance. On 
careful examination one should be able to discriminate between an enlarged 
left lobe of the liver and the spleen. 

The movable spleen in women with enteroptosis is occasionally seen, 
without symptoms or with the nervous phenomena usually associated 
with a movable kidney. As in the movable kidney, the pedicle may become 
twisted and produce alarming symptoms, demanding an immediate opera- 
tion. A suitable abdominal supporter may hold it in place, or operative 
interference may be necessary. It has been removed, and it has also been 
replaced and packed about with gauze to form adhesions. 

The spleen may rupture from the effects of an injury or very rarely 
spontaneously in typhoid fever and malarial disease. It becomes very pain- 
ful and sensitive; there is internal bleeding; and collapse and death result, 
unless an arrest of haemorrhage by operation is accomplished. 

The malarial spleen is large and hard, and occasionally reaches down 
into the pelvis. When the Plasmodium malarim cannot be found in the 
blood taken in the usual way, it occasionally may be discovered in the 
blood taken by needle puncture from the spleen. 

Malignant new growths are rare and fatal. 



674 



DISEASES DUE TO FAULTY METABOLISM 



Splenic Anaemia 

This disease was formerly regarded as the splenic form of Hodgkin's 
disease. It is defined as an idiopathic enlargement of the spleen with 
anaemia. 

The aetiology is unknown, and it is not known whether this form of 
anaemia is secondary to the splenic enlargement or not. Adult males con- 
stitute the largest number of patients. Splenic enlargement with profound 
anaemia is observed in children (see section on Diseases of the Blood). 

Pathology. — The enlarged spleen shows atrophy and sclerosis of the 
Malpighian corpuscles. The lymphatic glands may be slightly enlarged. 
The blood shows a secondary anaemia. 

Symptoms. — There is the gradual development of the subjective symp- 
toms of anaemia, although the patient does not look particularly anaemic. 
The spleen is very large, often reaching as far as the umbilicus. This en- 
largement in some patients seems to precede the anaemia. There have been 
haemorrhages from the stomach in some cases, and some patients pass blood 
with their stools. These haemorrhages may be very severe, almost fatal. 
Ascites may be present, with or without cirrhosis of the liver. The red 
blood corpuscles are diminished, averaging about 3,000,000, and the haemo- 
globin is relatively low. The leucocytes are usually diminished, and there is 
nothing extraordinary in the proportion of the different forms. Often 
there occurs a pigmentation of the skin, with subsequent emaciation and 
weakness. 

Course. — The duration of the disease seems to be from six months to 
five years or more. Patients may remain in fairly good health during this 
time, but have occasional haemorrhages. 

Differential Diagnosis. — We have to distinguish this disease from 
splenic leucaemia, Hodgkin's disease with a large spleen, cirrhosis of the liver 
with an enlarged spleen, and old cases of malarial disease with a large 
spleen. Pernicious anaemia usually has its blood condition to distinguish it. 
The red blood cells may be similar in both, making the diagnosis difficult. 
Usually the condition of the blood, associated with the large spleen and 
the tendency to haemorrhages, is clearly diagnostic of splenic anaemia. 

Treatment. — In general, the treatment is that for anaemia. Extirpa- 
tion of the spleen has not given satisfactory results. The prognosis is bad, 
although the patient may live many years in comparative comfort. 



CHAPTER XXVII 



THE NERVOUS SYSTEM; NEUROLOGICAL MEMORANDA 

Synopsis: Remarks on the Clinical Pathology of the Nervous System. — Remarks on the 
Application of Electricity. — Examination Scheme in Nervous Derangements. — Neu- 
ralgias. — Disturbances with Predominating Undue Motion. — Disturbances with Loss 
of the Power of Motion Predominating. — Disturbances with Loss of Consciousness 
Predominating — Derangements with Psychical Alterations Predominating. — Vaso- 
motor and Trophic Disturbances. — Meningitis in Adults. — Syphilis of the Nervous 
System. — Miscellaneous Lesions of the Brain and Cord with Pressure Symptoms, in 
which Localization and Surgical Aid are Possible. — Remarks on the Sympathetic 
Nervous System. — Anatomical and Physiological Anomalies. 

REMARKS ON THE CLINICAL PATHOLOGY OF THE 
NERVOUS SYSTEM 

The nervous system stands at the head of psychic and bodily phenomena. 
When the entire nervous system is disturbed there are general symptoms. 
When the integrity of individual nerves and ganglia is disturbed there are 
localized symptoms, as shown in the various motor, sensory, secretory, reflex, 
trophic, electrical, and circulatory phenomena. The pathology of the central 
nervous system embraces congenital malformations, injury, compression, 
and circulatory disturbances (such as anaemia, hypersemia, haemorrhage, 
embolism, and thrombosis), acute inflammation, softening, sclerosis, 
chronic inflammation, syphilis, tuberculosis, carcinosis, parasitic invasion, 
cavity formation, etc. The lesion may be unilateral, bilateral, or in dis- 
seminated plaques. In a broad sense the integrity of the central nervous 
system depends largely upon a good circulation, provided that the blood 
contains normal ingredients. 

The cerebrospinal nervous system is practically made up of various types 
of neurones. 

There are neurones transmitting nerve energy from the periphery of 
the body to the central nervous system. These are called centripetal neu- 
rones. The others carry the nerve impulse from the central nervous system 
to the periphery, and they are called centrifugal neurones. In the sensory 
system of neurones (centripetal neurones) there are usually three or four 
neurones ; in the motor system (centrifugal) there are only two. Our knowl - 
edge of the sensory neurones is not complete, so that it is difficult in 
most cases to recognize by the symptoms, in a lesion of the sensory 
system, whether this lesion is in the first, second, third, or fourth sensory 
neurone. 

When there is a lesion of the motor system the conditions are different. 
Here we can definitely state by the symptoms whether the lesion involves 

675 



676 



THE NERVOUS SYSTEM 



the central or peripheral motor neurones. If central, there is paralysis of 
muscles or spasticity of muscles. There is no trophic disturbance as a rule 
and no disturbance of electrical reaction. If peripheral, there are paralysis 
and trophic disturbance, such as atrophy of muscles, and disturbance of 
electrical reaction. 

The white matter of the central nervous system carries or transmits 
impulses. The gray matter receives and transmits impulses and may store 
potential energy to transmit impulses. The gray matter of the basal ganglia 
is the centre for automatic action. 

The gray matter of the spinal or medullary centre is the seat of reflex 
action. Each lower system is under constant control from above. The 
symptoms of a nerve lesion will be of a destructive or irritative nature, or 
show a combination of both. 

A neurosis is a functional derangement of the nervous system, exclusive 
of mental derangement, which is called psychosis. Neuritis means nerve 
inflammation. Neuralgia means nerve pain. 

Liquor Cerebrospinalis. — The brain and cord are surrounded by cerebro- 
spinal fluid, which evidently acts as a buffer to lessen shock and injury. 
This fluid stands under a positive pressure and contains but little albumin. 
When pressure and tension increase by reason of inflammatory processes, 
tumors, etc., the choked disc of the optic nerve ranks first in diagnostic 
importance. When pressure increases to the extent of compression of blood 
vessels, we observe symptoms 0} direct pressure, such as vomiting, slow pulse 
and respiration, epileptoid convulsions, and coma. 

Direct cerebral injuries, such as concussion of the brain or apoplexy, 
show the aforementioned respiratory and circulatory disturbances and gen- 
erally a loss of pupillary reaction. Embolic processes in the brain show 
about the same symptoms as apoplectic cases. 

MOTOR PHENOMENA 

Complete motor inability is called paralysis. Incomplete motor in- 
ability is called paresis. We speak of ataxia, incoordination, and athetosis 
when there is an uncertainty of movements. The causative factors of 
such motor disturbances may be psychical or may be due to pressure (tumor, 
haemorrhage) ; or they may be of inflammatory origin (infection by micro- 
organisms or action of toxines) ; or they may be due to circulatory dis- 
turbances in the nerve centres. Motor disturbances may also be due 
to pathological lesions in the muscle proper. To the latter group belong 
the muscular dystrophies, muscular rheumatism, muscular trichiniasis, and 
parenchymatous degeneration of muscle. 

Paralysis and Paresis 

Paralysis is a loss of motor power more or less complete. It may be 
associated with sensory disturbances and with muscle atrophy and reflex 
disturbances. 

There are four types, or classes: Monoplegia is a paralysis of one limb. 
Hemiplegia is a paralysis of one half of the body. Paraplegia is a paralysis 
of the two lower limbs. Diplegia is a paralysis on both sides. 



PARALYSIS DUE TO MUSCULAR DISEASE 



67? 



Paralyses may be central as a result of brain lesion, as in hemiplegia, 
they may be due to cord lesions, or they may be peripheral, as from 
neuritis or disease of the muscles. 

The cerebral type of paralysis is usually unilateral, involving the 
whole half of the opposite side of the body, including the lower half of 
the face (possibly with aphasia) 
and deviation of the tongue to 
the paralyzed side. The muscle 
condition expresses itself usu- 
ally by absence of atrophy or 
wasting. Another characteristic 
of brain palsy is the spasticity, 
or rigidity with exaggeration of 
reflexes. There is only a slight 
quantitative electrical change. 

Spinal paralysis (when the 
peripheral motor neurone is in- 
volved) is characterized by a 
toasting of muscle and, except in 
myelitis, absence of sensory dis- 
turbance. We observe in spinal 
paralysis flaccidity instead of 
rigidity and a diminution or loss 
of reflexes and the reaction of 
degeneration. 

Paralysis Due to Disease of 
the Nerves in the Course of 
Their Distribution. — This form 
may be traumatic or toxic. 
The traumatic paralyses fol- 
lowing dislocation, fracture, 
and pressure of any kind are 
generally local, and a return 
of electrical response, faradic 
and galvanic, indicates recov- 
ery of the nerve. The toxic 

forms are generally bilateral, with a loss of reflexes and muscular ex- 
citability, such as in alcohol, arsenic, and lead neuritis, etc., and in 
paralysis following infectious diseases (the syphilitic form is irregular in 
distribution) . 

Paralysis Due to Muscular Disease. — In this form the changes are 
in the muscles themselves, as in pseudohypertrophic paralysis and the 
scapulohumeral type of wasting. In these cases there is probably some 
congenital developmental defect. The electrical reaction is quantita- 
tively reduced. 

Paralysis and wasting of muscles associated with joint affections are 
of great practical importance. In rheumatoid arthritis there is a bilateral 
joint affection with enlargement of the bones, and the muscles become so 
atrophied that the patient resembles a skeleton. 




Fig. 210. — Spastic Paraplegia. 



678 



THE NERVOUS SYSTEM 



The seat of the disturbance known as myotonia (Thomsen) and myasthenia 
gravis pseudoparalytica is not definitely known. 

Finally, we note motor disturbances due to disease of the bones, tendons, 
and joints with intact muscles and intact nerve centres. 

Disturbances of motor coordination, such as tabes dorsalis, are believed 
to be due to a lack of centripetal impulse and defective or increased reflexes 
from various organs of special sense. Incoordination may be of cerebral, 
cerebellar, or spinal origin. 

Contractures (Active and Spastic). — Under certain conditions muscles 
for a time in a state of contracture will continue to be thus contracted and 
interfere with the free mobility of joints, and contrawise injury to, or lesion 
of, sensory nerves taking their origin in a joint, will produce contraction of 

muscles. Hysterical contractures are looked 
upon as of psychic origin. 

Neuropathic arthritis and osteitis, sup- 
posed to be due to analgesia and anaesthesia, 
are observed in cases of tabes, syringomyelia, 
paralysis, apoplexy, and trauma. 

Athetoid Movements; Athetosis. — Lesions 
in the motor tracts sometimes give rise to 
clonic spasms with slow, peculiar movements 
of the fingers and toes which are indepen- 
dent of voluntary action. They are a sequel 
of hemiplegia and may be mistaken for 
chorea in children. 

Tremors are divided into those which 
occur during voluntary movements (inten- 
tional tremors), those which are constant, 
but increased by voluntary movements, such 
as tremors following acute infectious dis- 
ease, and those which diminish after volun- 
tary movements. 

Choreic movements mean sudden jerking 
and incoordinate movements, forced move- 
Fig. 211. — Muscular Dystrophy, ments, the patient being forced against his 

will to move in a certain direction. 
Associated Movements. — A movement in a non-paralyzed limb causes a 
movement on the affected side. 

Convulsions, or spasms, are tonic or clonic in character. A tonic con- 
vulsion is a continuous contraction, as in tetany and tetanus. In clonic 
spasms contraction and relaxation of a muscle alternate rapidly, as in 
epileptic convulsions. 

The symptoms, differential points, and management of a convulsive 
seizure are discussed in a separate chapter (see also Paediatrics). 




SENSORY, SECRETORY, AND SPECIAL SENSE PHENOMENA 679 



SENSORY, SECRETORY, AND SPECIAL SENSE PHENOMENA 

Pain, hyperesthesia, and paraesthesia are due to irritative lesions in the 
sensory tract. Destructive lesions of the sensory tract result in 

1. Anaesthesia (hemianesthesia), loss of tactile sensibility, which is 
tested by touching the part with a light object. 

2. Analgesia, loss of sensibility to pain, 
which is tested by pricking the part with a pin. 

3. Distorted temperature sense, which is 
tested by alternately touching the parts with 
a hot and a cold test tube. 

4. Loss of muscle sense. This causes an 
ataxia, or an incoordination, in movements. 

Disturbances of localization are dependent 
upon the organs of special sense. 

Secretory disturbances are manifested by an 
increase or diminution of glandular secretions. 

Special Sense Symptoms. — For symptoms 
referable to the sense of smell, see Rhino- 
logical memoranda. 

For symptoms referable to the sense of 
taste, see Digestive disturbances. 

For symptoms referable to the sense of sight 
and hearing and for pupillary phenomena, see 
Ophthalmic and Otic memoranda. 

REFLEXES 

The disturbances of reflex action present 
very complicated conditions, and even in health 
there is a great difference in the intensity of Fig. 212. — Muscular Dys- 
reflex phenomena. Any irritation of superfi- trophy. 
cial tissues will cause contraction of neighbor- 
ing muscular elements, viz.: epigastric, cremasteric, plantar, conjunctival, 
pupillary, and palatal reflexes. They are distinguished as skin reflexes, 
deep reflexes (tendons and muscles), visceral reflexes (rectum, bladder, and 
genital apparatus), and organic reflexes (respiration, etc.). 

The absence of cutaneous reflexes is not of much clinical significance. 
Examples of reflex activity are sneezing, winking, coughing, a flow of saliva 
or gastric juice, vomiting, and blushing. Without these life would cease. 
The skin reflexes are at present not well understood. 

The deep tendon reflexes about the knee and ankle are generally present 
in health, and absence of the knee jerk generally denotes a lesion of the 
reflex arc. The author has met with individuals in good health with absent 
knee reflexes, and in some it is a family trait. Great care must be Used in 
designating a reflex as diminished or exaggerated, because we have no 
reliable standard of what is normal. The light reflex should never be over- 
looked. 

The so called organic reflexes preside over defalcation, urination, swallow- 
44 




680 



THE NERVOUS SYSTEM 



ing, and respiration, and their altered function is of great importance. In 
strychnine poisoning and tetanus the reflex spasm is due to great irritabil- 
ity of the spinal cord. An alteration of reflex action takes place when the 
connection between the brain and the reflex centre in the spinal cord is 
destroyed, but even in health there is a great difference in the intensity 
of reflex phenomena. 

There is a pathologically increased reflex activity due to irritation. 
Mild irritants and slight causes do not affect the reflex mechanism, else we 
should be in constant danger. The control of reflexes by the higher centres 
is important, and a defect therein is the cause of inharmonious reflex 
activity. Nature directs attention to the seat of irritation by pain and 
discomfort, and when a source of irritation is not clear, the reflex neurosis 
is not usualty due to peripheral irritation, but to a defect of a higher control 
from impaired nutrition. Thus, an increased nutrition of the entire system 
will counteract cortical exhaustion and cure "womb strain" and "eye strain," 
for which much unnecessary surgical interference is offered and accepted. The 
same reasoning is applicable to convulsive seizures supposed to be due to 
phimosis, for which the probable underlying cause is usually a weak nervous 
system. 

TROPHIC DISTURBANCES 

Trophic disturbances in the various tissues are usually the result of 
faulty circulation or innervation. When a muscle is so affected, a degenera- 
tive atrophy takes place. A most remarkable trophic disturbance of mus- 
cular nutrition is known clinically as progressive muscular dystrophy 
(pseudohypertrophic muscular paralysis), occurring mainly in children. 

In the acute anterior poliomyelitis of children the trophic disturbance 
may be so marked that a retardation of bony growth goes hand in hand with 
the atrophy of the paralyzed and degenerated muscles. Trophic vasomotor 
disturbances in the skin and mucosa are the causes of such conditions as 
urticaria, erythema, bed sores, and herpes zoster. Other vasomotor dis- 
turbances are pallor, coolness, congestion, and cedema of the skin. 

REMARKS ON APHASIA 

Aphasic disorders occur in connection with lesions of the left cere- 
bral hemisphere. We distinguish motor, or ataxic, aphasia (third left 
frontal convolution), sensory word deafness (first temporal convolution), 
amnesic aphasia (a failure to recall words) , and aphasia which may be simple 
or mixed. In conjunction with disorders of speech, difficulty in reading 
(alexia), writing (agraphia), and communication by gesture (amimia) may 
occur. Aphasia occurs commonly with right sided cerebral hemiplegia. 
Aphasia without motor paralysis occurs with small circumscribed lesions 
or it may be transitory in consequence of circulatory disturbance. Sensory 
aphasia is not accompanied by motor disturbance. Aphasic disturbances 
may be improved by attempts at speech, exercise, etc. 

PSYCHICAL CONDITIONS 

In the emotional sphere we observe changes of habitual temper, such as 
irritability of temper, mental depression, and mental excitation. 



REMARKS ON THE APPLICATION OF ELECTRICITY 



681 



The disorders of intellection embrace dulness, confusion, loss of memory. 

Characteristics of the insanities: Delusion, an abused or unformed belief, 
illusions, false interpretation of objects, hallucinations, a sense of percep- 
tion without a physical basis. 

Delirium is characterized by restlessness or incoherence of speech, with 
illusions and hallucinations. It may be active or wild, as in delirium 
tremens, low or muttering, as in " typhoid" states. The onset may be sudden 
or slow. In the beginning of an acute infection it is the expression of pro- 
found toxaemia, and as a terminal phenomenon it may express brain inani- 
tion from circulatory failure. 

Insomnia (Sleeplessness) 

Patients complain of disturbed sleep, persistent wakefulness, sudden 
twitching or jerking of the body at the time of falling asleep, etc. 

Disturbed sleep has slight diagnostic value, because of its occurrence in 
slight as well as serious ailments in neurotic persons and from mental or 
physical fatigue or indulgence in tea, coffee, tobacco, etc. 

Disturbances of consciousness, according to their degree or severity, are 
termed somnolence or lethargy, stupor or coma. 

In coma there is the condition of insensibility from which we cannot 
arouse the patient. 

The differential diagnosis and treatment of coma are very important, 
and are described in a separate chapter (see Coma). 

FAMILIAR POINTS IN CEREBRAL LOCALIZATION 

In the cerebral corticomuscular region is the centre for the leg, arm, 
and facial nerves. The cortex of the frontal portion is associated with 
thought and intelligence; the right and left temporal lobes contain the 
cortical radiation of auditory nerves. The occipital portion contains the 
cortical radiation of the optic fibres. The left temporal lobe is the sensory 
speech centre. 

Internal Capsule. — Haemorrhage into the internal capsule is a common 
disorder, resulting in paralysis of the facial and hypoglossal nerves, in 
paralysis of the arm and leg upon the other side, and sometimes in cuta- 
neous anaesthesia. 

Disease of the Cerebral Peduncles. — This disease results in cerebral hemi- 
plegia with alternate oculomotor paralysis. 

Disease of the Pons. — Hemiplegia with alternate facial paralysis. 

Base of the Brain. — When disease of the base is associated Math inflamma- 
tion, thickening, and neoplasms, the cerebral nerves are compressed and 
paralyzed. The principal bulbar symptoms are derangement of articulation, 
swallowing, breathing, and cardiac action, through the hypoglossal, glosso- 
pharyngeal, and vagoaccessory nerves. 

REMARKS ON THE APPLICATION OF ELECTRICITY 

Electrical power may be compared to water power. The force which 
starts the column of water flowing is gravity, that of electricity is 



682 



THE NERVOUS SYSTEM 



electromotive force (E. M. F.). Electricity flows from a high potential 
(the positive pole) to a low potential (the negative pole). The zero point is 
the earth, and the potential is the capacity to do work. The unit of measure- 
ment of electromotive force is the volt. 

Substances through which electricity flows are conductors in contra- 
distinction to non-conductors, or insulators. 

The unit of resistance to the electrical current is the ohm. 

Ohm's Law. — The current strength is equal to the electromotive force 
divided by the resistance. 

The current strength is measured and expressed in amperes. For thera- 
peutical purposes, we gauge the current strength in milliamperes (yoVo of 
an ampere). 

The forms of electricity used in medicine are the constant current 
(galvanic current), the interrupted current (faradic current), static electric- 
ity (Franklinism), the sinusoidal current, and the D'arsonval, or high fre- 
quency, current. 

The galvanic current is produced by chemical action. The faradic cur- 
rent is produced by induction in a secondary coil surrounding a primary 
coil in activity, with frequent interruptions. Static electricity is produced 
by friction and confined by insulation. 

Action of the Electric Current wpon Living Tissues 

Electrolysis is a chemical decomposition of tissues at the electrodes — a 
process taken advantage of for the destruction of nsevi, small tumors, etc. 

Cataphoresis is the power of carrying solutions through the tissues in 
the direction of the current. Cocaine and other drugs may thus be intro- 
duced into the body. 

Electrotonus is a modification of the nerve electricity by means of the 
electric current. At the anode it is lessened (anelectrotonus) ; at the cathode 
it is increased (catelectrotonus). A sudden increase or decrease of the 
current (voltaic alternative) also causes muscular contractions. The 
galvanic current possesses all these properties in a more marked degree than 
the faradic current. 

A degenerating muscle loses the power of response to static electricity 
first, next to faradic, then to simple opening or closing of the galvanic 
current, and finally to the voltaic alternative. 

Reaction of Degeneration. — 1. Loss of muscular contraction to nerve 
stimulation by the galvanic or faradic current. 2. Loss of muscular 
contraction to direct stimulation by the faradic current. Modification 
(sluggish contraction) of muscular contraction by stimulation with the 
galvanic current. 

Thus electricity may aid us in forming a prognosis, for a complete re- 
action of degeneration implies a more grave prognosis than a partial one. 

ELECTRICITY IN PRACTICE 

In medical practice we employ electricity 

1. As a tonic. 

2. As a sedative for the relief of pain. 



EXAMINATION SCHEME IN NERVOUS DERANGEMENTS 683 



3. For diagnostic purposes. 

4. For the destruction of tissue. 

5. For the production of light and power. 

The faradic current is employed for general tonic purposes in central 
paralyses, as well as in peripheral paralyses when the muscle is but slightly 
degenerated. In applying the rapidly interrupted current, we place one 
electrode over the nerve supplying the muscle and stroke the paralyzed 
part with the other electrode. This method does not necessitate an exact 
knowledge of the position of the motor points, a motor point being a certain 
spot in each muscle at which the action of the current is more irritating. 
One application each day or every other day is sufficient. 

For stimulating anaesthetic skin, we make use of a wire brush attached 
to the faradic battery. Faradization for general tonic purposes is accom- 
plished in the following manner: Groups of muscles are made to contract 
separately, after which the poles are placed at the nape of the neck and the 
cheek. Such treatment may be administered daily. 

The galvanic current is also employed as a general tonic and in about the 
same way as the faradic. To influence the nutrition of degenerated muscles, 
the anode is placed over the supply nerve and the cathode is rubbed over 
the muscle without breaking the current. To produce muscular contrac- 
tions, the cathode is placed over the motor point and the circuit is alternately 
opened and closed at this point. 

Static electricity is used for tonic effects by drawing sparks from various 
parts of the body. An induced static current can also be obtained, and 
may be used as a muscle stimulant in central paralyses. Vacuum glass 
electrodes may also be employed in connection with a static machine. 

Sedative influences may be elicited by drawing sparks by means of a static 
current from the painful area or by placing one faradic electrode over the 
painful area. When using the galvanic current as a sedative, we place the 
anode over the part to be influenced and the cathode as far away as possible, 
and we employ a strong current frequently. 

In cataphoresis for neuralgia the anode is saturated with a 10 per cent 
cocaine solution. 

In applying electricity, the electrodes must be thoroughly saturated with 
water; dry electrodes are used to influence the skin. To avoid painful 
shocks from a strong galvanic current, we should increase or decrease the 
strength gradually, and to produce muscular contraction we always begin 
with a weak current. 

For electrolysis we employ the constant current, one pole of which is a 
needle. 

The high frequency current has been employed to stimulate internal 
secretions. 

EXAMINATION SCHEME IN NERVOUS DERANGEMENTS 

In taking the history of a patient with a nervous disease, it is particularly 
important to inquire into the family peculiarities and diseases. We should 
ask about neurasthenia, epilepsy, hysteria, insanity, alcoholism, tuberculosis, 
rheumatism, gout, and syphilis. The previous illnesses of the patient, 



684 



THE NERVOUS SYSTEM 



particularly syphilis and the infectious diseases, are important. As to the 
causes of the present trouble, we should inquire about trauma (injury at 
birth), fright, and poisoning (lead, mercury, alcohol, and tobacco), the gouty 
diathesis, infectious diseases (scarlatina, influenza, meningitis, etc.), and 
syphilis. 

Present Illness. — We should ask about headache, vertigo, sleep, tremor, 
delirium, abnormal disposition, and disturbances in sensation and motion. 

EXAMINATION 

Motor Power. — In the examination we should ascertain the motor power as 
shown by the position of the extremities in repose, an abnormal position, 
atrophies, and involuntary motions, such as trembling and spasm; motion, 
particularly active free motion, activity with point of resistance, passive 
motion. 

The Face. — We should notice whether both sides of the face are equal, 
whether the palpebral fissures are the same on both sides, whether the nos- 
trils are equal, whether the mouth is straight or retracted, whether the 
eyes are equal and held motionless, whether the pupils are equal, whether 
the patient can wrinkle the forehead, close the eyes, pucker the lips, laugh, 
fill out the cheeks, extend the tongue and move it to the right or left, what 
is the state of the movements of mastication, notice the movements of 
the eyes (to the right, to the left, upward, downward, and inward). 

Mouth; Pharynx; Larynx. — Examine particularly the condition of the 
soft palate and uvula and the ability to move the soft palate when 
intonating. 

The neck should be examined especially as to the position of the head 
and the ability to move it to the right to the left, forward, or backward 
(try with a point of resistance). 

The Shoulders and Arms. — You will notice as to the position of the 
scapula, the position in which the arm is held, the posture of the fingers, 
the thickness of the thenar and hypothenar eminences, and the interosseous 
spaces; as to the ability to raise the shoulders and arms (to the vertical 
position), to abduct them, to extend them horizontally, to bend and extend 
the forearm, to pronate or supinate it, to bend and extend the hands and 
fingers, to separate the fingers, to bend in the whole thumb, and as to the 
hand pressure. 

The legs will be examined as to the position of the trochanters, con- 
cerning the ability to raise, abduct adduct, and bend and extend the knee, 
ankle, and foot. 

The Trunk. — Notice the respiration, whether it is the same on both sides 
of the body; as to the abdomen, whether it is retracted; concerning the ver- 
tebral column (shape) and the buttocks (hypertrophy, atrophy) ; as to 
bending forward, backward, to the left, and to the right, deep respiration, 
and cough. 

The Reflexes. — Such as the skin reflex, the sole and palmar reflexes, the 
cremasteric, abdominal surface, conjunctiva, lid, and pharyngeal reflexes, 
the tendon and muscle reflexes, the patellar and tendo Achillis reflexes, 
the ankle clonus, the wrist, biceps, and triceps tonus, and the pupil reflex. 



FORMS OF NEURALGIA 



685 



Miscellaneous Phenomena 

Bladder and Rectum Phenomena. Romberg's symptom. Gait (abil- 
ity to cross the legs in the prone position, etc.) ; as to the grasping of 
objects; as to speech and handwriting; as to the perceptive faculty — sub- 
jective (deafness, irritation, pain, etc.) and objective; as to skin sensation 
on stroking softly, on pricking, and on applying heat or cold; as to the 
muscular sense — the ability to move, the field of vision, the hearing, smell, 
and taste. 

THE NERVE CLINIC 1 

NEURALGIAS; PAINFUL TICS; HEADACHE; MIGRAINE 

Neuralgia is a name applied to an ailment characterized by pain along 
the course of a nerve or nerves, which may be of central or peripheral origin, 
and may be idiopathic or symptomatic. 

.(Etiology. — The predisposing cause is a neurotic, gouty, or rheumatic 
constitution. The exciting causes are toxic agents, including autointoxica- 
tion from the intestine (dyspepsia, constipation), acute and chronic infec- 
tious diseases, exposure, overexertion, emotional shock and injury, and 
direct irritation, as from a carious tooth or tumor. Syphilis, tuberculosis, 
malaria, diabetes, Bright's disease, tabes, and alcoholism are among the 
principal underlying causes. Neuralgia may be reflex from the pelvic and 
other organs. 

Forms of Neuralgia 

Cervicooccipital neuralgia (neck pain) is not rare. It is more common in 
women between the ages of twenty and thirty-five. Neck pains occur in 
migraine, in hysteria, in neurasthenia, from spinal irritation, as a result of 
eye strain, as a symptom of brain tumor, meningitis, or rheumatic inflamma- 
tion of the neck muscles and nerves, and often as a reflex of pelvic dis- 
ease. As a true neuralgia, the pain is usually unilateral, paroxysmal, sharp, 
and sometimes intense. One may demonstrate tenderness over the exit of 
the nerves. The disease may last for several weeks. 

Cervicobrachial neuralgia is a painful condition of the sensory nerves 
of the neck, shoulder, and arm. It is rather rare, more common in women, 
and is produced by the usual causes of neuralgia. There may be an accom- 
panying neuritis with burning sensations. Anaesthesia, vasomotor dis- 
turbances, herpes, muscular weakness, and atrophy may be present. 

Digital neuralgia, where the pain occurs in a single finger, is sometimes 
seen. It is often due to a local injury or neuritis. As a reflex it may be 
due to a remote trouble. 

Supraorbital and infraorbital neuralgia is marked by shooting pains and 
tenderness along these nerves, by painful spots at the supraorbital notch, 
at the inner angle of the orbit, at the junction of the bone and cartilage of 
the nose, and over the infraorbital foramen. In protracted cases the hair 
on the affected side may become gray. 



1 For familiar forms of nervous derangements in children see also " Paediatrics." 



686 



THE NERVOUS SYSTEM 



Supramaxillary neuralgia causes pain referred to the teeth of the upper 
jaw. A painful point may be elicited at the infraorbital foramen. 

Inframaxillary Neuralgia. — The pain is experienced in the teeth of the 
lower jaw, and painful spots may be found along the auriculotemporal 
nerve. 

Tic douloureux (prosopalgia, FothergilPs neuralgia) is a special form of 
trigeminal neuralgia and is to be clearly distinguished from the ordinary 
form. It is accompanied by distinct changes in the nerve itself. It seldom 
occurs in people under forty, and is often seen in the very old. The disease 
is characterized by intense darting pains, usually starting in the upper lip, 
by the side of the nose, and radiating into the teeth, into the eye, or over 
the temple, brow, and head. They occur on only one side of the head. The 
patient is in great agony during the attack; the face flushes, the eyes water, 
and the nose runs. After lasting for a few minutes, the pain becomes less, 
but seldom ceases entirely, and a breath of cold air, speaking, eating, or 
protruding the tongue may bring on spasms. They are worse in winter. 
Sometimes the spasms come for several months every year, usually in the 
spring. The face may assume spasmodic movements with the pain. This 
form of neuralgia differs from ordinary forms because a pathological con- 
dition of the nerve is found (neuritis). 

Intercostal neuralgia (side pain) is frequently seen in nervous, hysterical, 
and anaemic women. In aneurysm, caries, and pleurisy there may be pain 
along the intercostal nerves. Corset pressure, childbearing, pelvic disorders, 
dyspepsia, heart disease, syphilis, malaria, and lead poisoning are frequent 
causes. The attack usually comes on suddenly. The pain is sharp and 
stabbing and but slightly increased with the respiratory movements. There 
are points of tenderness at the exit of the lateral nerve branches or over 
the exit of the dorsal or anterior branch. Pleurodynia is recognized by not 
shoiving any of these tender spots, and by increase of the pain upon breathing. 
Herpes zoster may occur with the severe form of intercostal neuralgia. Its 
course is from two to six weeks, but it may last longer. 

Mammary neuralgia (mastodynia) is a form of intercostal neuralgia 
affecting the anterior and lateral branches of the three or four upper dorsal 
nerves. It may be a true neuralgia or due to local tumors. Anaemia, 
pendent breasts, poorly fitting corsets, injury, hysteria, sexual precocity, 
pregnancy, and lactation are causes. It is often severe, and middle aged 
women affected with it worry for fear of cancer. 

Lumboabdominal neuralgia, pain along the upper branches of the lumbar 
nerves, occurs oftenest in women, and, in addition to the ordinary causes of 
neuralgia in this region, there may be straining, constipation, and pelvic 
disease. We find pain in the loins, back, buttocks, down to the hypo- 
gastrium, in the inguinal canal, spermatic cord, testis, scrotum, or labium 
majus. Painf ul thigh, with pain in front of the knee and anterior and outer 
parts of the thigh, is a common form. 

Coccygodynia affects the lower posterior branches of the sacral nerves. 
Exposure, injury, and parturition are causes. Reflexly it can be caused 
by pelvic disease or spinal irritation. It is most annoying, as it interferes 
with walking, sitting, and defalcation. 

Surgical treatment is rarely needed. 



GENERAL PRINCIPLES OF TREATMENT OF NEURALGIAS 687 



Sciatica, a neuralgia, sometimes a neuritis, of the sciatic nerve, is charac- 
terized by an intense pain extending down the back of the thigh and some- 
times down the leg to the foot. 

It is a disease of middle life and it is more frequent in men, being the 
only form of neuralgia of which this can be said. In addition to the ordinary 
causes of neuralgia, in this form we recognize as exciting causes constipa- 
tion, pressure from hard seats, exposure, muscular strain from heavy work, 
and pressure due to intraspinal or intrapelvic tumors, etc. We sometimes 
see it in diabetes, phthisis, alcoholism, and metallic poisoning. 

Although the pain may be uniformly distributed along the course of 
the nerve, not infrequently there are spots where it is more intense. These 
spots are above the hip joint, near the posterior iliac spine, at the sciatic 
notch, about the middle of the thigh, behind the knee, below the head of the 
fibula, behind the external malleolus, and on the back of the foot. Pressure 
usually elicits tenderness along the course of the nerve. Generalty the pain 
is more or less constant and of a gnawing, burning character, but not infre- 
quently it is paroxysmal, being more intense in damp weather and at night. 
Walking increases the pain. The patient does not straighten his knee, but 
walks on his toes to diminish tension on the nerve. In severe cases there 
may be muscular wasting and fibrillary twitchings. 

Diagnosis. — We have to distinguish sciatica from rheumatoid and hys- 
terical hip joint disease, organic diseases of the cauda equina, or spinal cord, 
muscular pains in the hip and leg, and tumors pressing on the nerve. 

The prognosis must be guarded, as some cases prove intractable to 
treatment and some last for months. 

Podalgia is a term used to indicate pain in the feet, of whatever origin. 
Pains in the feet occur in flat foot, gout, rheumatism, syphilis, tabes, chronic 
alcoholism, and diabetes. Gouty pains are usually in the dorsum of the 
feet, alcoholism pains affect the ankle, syphilitic pains are accompanied with 
nodes. 

Plantar Neuralgia. — Occasionally in sciatic neuralgia the pain is limited 
to the plantar nerve. This condition is probably due to a neuritis. Eryth- 
romelalgia is a painful trophic disturbance in the fingers and toes. 

Morton's neuralgia is a name given to the pain in the metatarsophalan- 
geal joint of the third and fourth toes which is thought to be due to slight 
dislocation and resulting pressure upon a nerve. The dislocation may 
come from injury or the pressure of the shoe. However, it may affect other 
toes, and may not be due to a luxation. Incipient flat foot may cause it, 
and it has been seen in pregnancy. 

Tarsalgia (policemen's or bakers' disease) is a neuralgia probably due to 
incipient flattening of the foot and stretching of the plantar ligaments. It 
has been ascribed to other causes. It is observed in people who have been 
in the habit of going barefoot and then taking a position where much walking 
or standing was necessary. 

General Principles of Treatment of Neuralgias 

We should seek to relieve the underlying cause, build up the general 
health by exercise and cold sponge baths, and treat the pain symptomati- 



688 



THE NERVOUS SYSTEM 



cally. The nervines, analgetics, and occasionally morphine are indicated. 
In the less urgent cases it is wise to begin treatment with a brisk purge. 

Symptomatically, we may give antipyrine, acetanilide, phenacetin, the 
salicylates, caffeine, the bromide of ammonium, or sodium, and sometimes 
morphine, codeine, or hyoscine. Local applications of a 20 per cent solution 
of menthol, hot cloths, ice bags, blisters, etc., are aids. Morphine in neu- 
ralgias should be injected over the seat of the pain. 

A combination of the various analgetics sometimes acts better than an 
individual drug. 

When syphilis or malaria is suspected as an underlying cause, mercury, 
iodide of potassium, quinine, and arsenic are to be administered, and iron 
in ansemia. Massage and vibratory massage are often useful. In intractable 
cases surgical procedures are sometimes necessary. 

Treatment of Tic Douloureux. — Nitroglycerine, gr. tot every two hours, 
gives relief. Aconitine, gr. -gfo in repeated doses until the physiological 
effect is obtained, is probably the best single remedy. Morphine and cocaine 
injections, galvanism, potassium iodide, gelsemium, croton chloral, codeine, 
menthol, etc., are all helpful. Tonics and change of air have helped. 
Vibratory massage may be tried. 

Surgical interference may be necessary. Removal of the teeth is usually 
unsuccessful. 

Treatment of Sciatica. — Look for local irritation and the underlying 

cause, and apply general principles of treatment. 

For the pain, we may give antipyrine, phenacetin, lactophenin, chloral 
hydrate, the bromides, and cannabis indica. Subcutaneous injections of 
strychnine into the nerve or the region of the pain have lately proved a 
valuable means of treatment. Injections of morphine over the nerve give 
prompt relief. In some cases the wet pack and dry hot air treatment are 
curative if employed for several weeks. 

The surgical treatment of sciatica consists of the stretching — subcutaneous 
or open — acupuncture, and even excision of part of the nerve. In the sub- 
cutaneous stretching the thigh is forcibly flexed upon the abdomen while 
the leg is kept in full extension. It is without danger and should be tried 
in every case. 

In pedal neuralgia, rest, wearing broad soled shoes, and supporting the 
plantar arch by means of spring soles are indicated. An operation is occa- 
sionally necessary. 

HEADACHE 

Headache (cephalalgia) is a broad term given to attacks of diffuse pain 
in different parts of the head and not confined to particular nerves. It is 
common to observe it in paroxysms, but it may be continuous. 

Etiology. — This most common of nervous symptoms is estimated to 
occur in from 10 to 15 per cent of school children, 25 per cent of men, and 
50 per cent or more of women. It may be caused by anaemia and other 
blood conditions; by gout, rheumatism, diabetes, and ursemia; and in infec- 
tions, malarial fevers, etc. Toxic cases arise from lead, alcohol, tobacco, or 
gastrointestinal toxaemia. ^Etiological neuropathic states are epilepsy, neuras- 
thenia, hysteria, and neuritis. Reflex conditions are ocular (eye strain), 



MIGRAINE; HEMICRANIA (SICK HEADACHE) 



689 



nasopharyngeal, auditory, dyspeptic, and sexual. Organic disease may 
cause it, such as arteriosclerosis, syphilis, tumors, meningitis, and diseases 
of the cranial bones. 

The various forms are frontal, occipital, parietal, temporal, vertical, and 
diffuse headaches. We observe pulsating, throbbing headaches, characteriz- 
ing vasomotor disturbances and usually indicating migraine. 

There are dull, heavy headaches which are typical of a toxaemia or 
dyspepsia; constrictive, squeezing, or pressing headache, common in neu- 
rotic and neurasthenic patients; and hot, burning, sore sensations, com- 
mon in rheumatic and anaemic cases. The sharp boring pains are seen in 
hysterical, neurotic, and epileptic cases. 

Diagnosis and Differential Points. — It is very important to determine the 
cause of a headache, and a consideration of the enumerated factors will aid 
in diagnosis. Dull headaches are to be distinguished from neuralgias of 
individual nerves and from migraine. 

Migraine is paroxysmal, lasts a short" time, and leaves the patient well 
or even better than before. It is often accompanied by nausea, flashes of 
light, strong pulsations, vertigo, and pallor or congestion of the face. 

Neuralgic pains follow the course of a nerve, where sensitive points may 
be found. They are sharp and shooting in character and are often associ- 
ated with suffusion of the eye and oedema and with pain on pressure over 
the affected nerve. In supraorbital neuralgia the pain is on the head, not 
in the head. 

Neurasthenic "headache " is not a pain, but a pressure sensation, though 
on violent overexertion real pain (exhaustion headache) may occur, as in 
the healthy. The complaint is often of a band drawn round the forehead; 
in more severe cases of a lead cap feeling. "Suggested " headaches occur 
principally in morbidly suggestible women, usually arise from slight causes, 
and are generally associated with complaints of other bodily sensations. 

Nodular headaches occur mostly in women of middle life. The pain 
originates in the occipital and cervical regions and is persistent and violent, 
and the patients are sensitive to atmospheric disturbances like rheumatics. 
Examination reveals millet seed to bean sized nodules in the subcutaneous 
tissue of the occiput and neck. 

Treatment of Headache. — When immediate relief is required, it is best 
to administer one of the analgetic drugs in a full dose (see Treatment of 
Neuralgia) . In less urgent cases a brisk purge may first be administered and 
an analgetic drug or specific medication, as with quinine, potassium iodide, 
or iron and arsenic, may be employed subsequently. In neurotic individuals 
the bromides are usually indicated, together with proper exercise and hydro- 
therapy. In nodular headache local massage and vibration are to be em- 
ployed. 

Migraine; Hemicrania (Sick Headache) 

Migraine is a constitutional neurosis, characterized by periodical attacks 
of pain, chiefly in the course of the fifth nerve. 

^Etiology. — It is often inherited, and is more common in women and 
members of neurotic families. Rheumatism and gout as latent conditions 
are known to be causative factors. Reflex causes are uterine disease, eye 



690 



THE NERVOUS SYSTEM 



strain, abnormal conditions of the nose or nasopharynx , and carious teeth. 
In young patients we should suspect a reflex origin. The exciting cause 
may be mental or bodily fatigue, emotions, indigestion, constipation, or 
some particular article of food. There is a periodicity to the attacks, 
which usually cease after the climacteric in women and at about the same 
age in men. 

Pathology. — We know nothing as to the pathological conditions. The 
theory that it is a nerve discharge from sensory centres, a sensory equivalent 
of epilepsy, seems tenable. Some call it a vasomotor neurosis. 

Symptoms. — Many cases show premonitory signs, such as malaise, 
lassitude, depression, or a sense of chilliness, lasting from a few hours to 
several days. Visual prodromes, such as hemianopia, spots of dimness 
of vision or scotoma, apparitions, balls or flashes of light, and zigzag lines 
are common. There may be a condition of intense emotional activity. 
The prodromal symptoms are not always present, or they may constitute 
the entire attack, the headache not taking place or being very slight. 
Confusion of ideas, a feeling of stupor, depression, and marked disturbances 
of memory for several hours may exist without the headache and constitute 
the complete attack. 

The most characteristic feature is the violent paroxysmal headache. 
The pain usually starts in one side of the head, over the eye, but may begin 
in the occiput. It increases and becomes excruciating, involving one half 
of the head or, more often, the whole of it. The quality of the pain is tense, 
throbbing, and blinding, and it is increased by jars, light, and noises. 
Prostration, although temporary, is extreme. The face may be pale and 
pinched, and there may be a difference between the two sides. During the 
attack there is usually mental confusion, with temporary loss of memory. 
The pulse is small and hard and may be slowed. When the headache 
reaches its climax, nausea and vomiting commonly appear, and they afford 
relief. Repeated vomiting causes a regurgitation of bile and bitter vomitus, 
which has given the affection the improper name of "bilious headache." 

The attack varies in length from a few hours to several days. After 
the patient has vomited and the pain has become easier, he usually falls 
asleep and awakes much refreshed, and the next day may feel better than 
before the attack. The attacks occur with considerable regularity, monthly, 
fortnightly, or even weekly. In women they often occur during menstrua- 
tion. After a severe attack we may observe small haemorrhages in the sclera 
of the eye. 

Prognosis. — Although the disease cannot be promptly cured, much can 
be done to lessen the frequency and severity of the attacks. 

Treatment. — Patients are frequently aware of the causes precipitating 
an attack, and if they are avoided, the paroxysms are much less frequent. 
In children, after eliminating eye strain, nasal hypertrophies, adenoid 
growths, enlarged tonsils, etc., we should endeavor to keep them in the best 
possible health by exercise, proper diet, and freedom from excitement and 
overstudy. As it has been demonstrated that the attacks are much less 
frequent during good health, the patient should be built up, the gouty and 
rheumatic tendencies should be corrected, and the digestive tract be kept 
in order by catharsis and the administration of dilute muriatic acid. 



OCCUPATION NEUROSES 



691 



During the paroxysm, the patient should be put to bed and kept ab- 
solutely quiet. A cup of strong coffee often relieves the pain. Antipyrine 
or phenacetin, in small repeated doses, frequently gives relief. In cases 
where there is marked pallor, nitroglycerine, in doses of yj of a grain every 
two hours, is helpful. Cannabis indica, gr. 3 (Herring's English extract), 
sodium bromide, gr. xxx, and chloral hydrate, gr. x to xv, are of service. 
A prolonged course of cannabis indica has been recommended. 

General massage and active outdoor exercise are to be advised. In the 
interval between the attacks the patient should have tonic baths and all 
forms of tonic hydrotherapeutics. 

DISTURBANCES WITH PREDOMINATING UNDUE MOTION 
OF CENTRAL, PERIPHERAL, OR UNKNOWN ORIGIN; 
TICS 

Tic convulsif is a very chronic disorder characterized by quick, electric- 
like spasms of groups of muscles or single muscles. There is a period of rest 
between the violent spasms. We see it limited to special nerves, especially 
the facial (mimic tic) , or to branches of nerves, as in the orbicularis, zygomat- 
icus, diaphragm, or tensor tympani. Sometimes the spasms are accom- 
panied with bursts of speech, as when the patient uses obscene language 
(tic impulsiv, coprolalia) or involuntarily repeats the last words of a sen- 
tence (echolalia) or spasmodically imitates a gesture (echokinesis) or in- 
voluntarily speaks out a thought, sometimes against his will (tic de pensee). 

The disease begins with these violent movements, which can be controlled 
for a time. They cease during sleep. The disease may last for years, and 
is best treated by isolation, when children are afflicted, by tonics, and 
ordinary antispasmodics, also by vibratory massage. 

Tic codrdine (habit chorea, habit spasm), which sometimes represents 
aborted chorea, is a peculiar trick of speech, gesture, grimace, shrug of the 
shoulder, twitching of the eye, or sniff, with which a person may go through 
life. When it is seen in children, the treatment is moral, hygienic, and 
medicinal. Head nodding is a form of habit spasm (see Paediatrics). 

Stammering is an improperly regulated motor impulse from the cortex of 
the brain. 

OCCUPATION NEUROSES 

Occupation neuroses are functional nervous disorders characterized by 
spasmodic, tremulous, incoordinate, or paralytic disturbances with the feel- 
ing of fatigue or pain upon attempting to perform the customary function 
the overperformance of which has brought it about. 

Writer's cramp is a typical form. Among the predisposing causes are 
heredity and a neuropathic constitution. Excessive worry, intemperance, 
and all debilitating influences are also predisposing. The exciting cause 
is excessive writing, but essential to its causation is a cramped position, in 
which the fingers alone are used, and the little finger or wrist is resting over 
the table. Free hand writing, with motions by the whole arm from the 
shoulder, is least harmful. Lead poisoning, exposure to wet and cold, and 
local injuries are sometimes exciting causes. 



692 



THE NERVOUS SYSTEM 



Symptoms. — It develops slowly with stiffness in the fingers and uncertain, 
jerky movements. There is fatigue and sometimes actual pain. Later, 
as soon as writing is attempted, the pen is likely to fly in all directions, 
and there is no coordination of movement. 

We may speak of four forms or degrees in order of frequency or progres- 
sion, but they are usually more or less mixed. 

1. The spastic form, the most common, is that in which there is a cramp, 
a tonic spasm of the muscles (sometimes the flexors and sometimes the 
extensors), usually those of the thumb and the first three fingers. The 
pronators and supinators may be affected. Then the thumb and first 
finger may alone be involved. There is also incoordination. 

2. The neuralgic form is that in which, in addition to the spasm, there 
are fatigue, pain, and sometimes tenderness along the arm. 

3. The tremulous form is rather rare. Upon attempting to write, there 
is a tremor of the fingers holding the pen, which may involve the forearm or 
even the whole extremity. It is an intention tremor. 

4. The paralytic form, more rare, is that in which the fingers seem power- 
less to hold the pen. Persistence and will power will cause pain and weak- 
ness, so that writing becomes impossible. 

There are other symptoms, mainly psychical, sensory, and rarely vaso- 
motor and trophic. Mental depression, emotional disturbances, insomnia, 
vertigo, pain, fatigue, numbness, prickling, pressure, weight, tension, con- 
striction, etc., may be present. There may be local swelling and a sensation 
of throbbing. Local sweating, dryness of the skin, and cracking of the nails 
may result. 

The electrical reactions are not uniform. The electrical examination may 
show the stage of the disease, as neuritis is undoubtedly present in some 
forms. 

The prognosis is unfavorable, but cases of complete recovery are oc- 
casionally seen and temporary improvement is frequently observed. 

Other Forms of Cramp. — Musicians' Cramp. — Pianists', violinists', 
flutists' , and clarionetists' cramps are very similar, with atrophy of certain 
muscles. Telegraphers' cramp, in which the extensors of the wrists and 
fingers are most affected, is rather common. Sewing spasm, in tailors, 
seamstresses, and shoemakers, is occasionally seen. The muscles of the 
hands are seized with clonic and tonic spasms upon attempting to use 
them. Drivers' spasm, cigarmakers' cramp, milkers' spasm, watchmakers' 
cramp, and photographers' cramp are rare. Ballet dancers' cramp is prob- 
ably a neuralgic affection. Artificial flower makers, billiard players, 
dentists, hide dressers, electrical instrument makers, stampers, turners, 
sewing machine operators, money counters, weavers, painters, and pedes- 
trians also may have occupation neuroses. 

Sacral nerve twitchings, tremor rigidity, clonic an'd tonic spasms, myo- 
clonus, and athetoid movements are seen as a part of some general or central 
disorder or as occupation neuroses. Saltatory spasm involves the legs alone. 

Chorea is described under the section on Paediatrics. 

Treatment of Tics. — Prophylaxis in writers' cramp. One should use a 
gold pen, smooth paper, and large cork or rubber penholders, making the 
motions from the shoulder, having the paper on the desk at an oblique angle 



PARALYSIS AGITANS 



693 



to the edge of the desk, and far enough away from the edge so that the elbow 
can rest on the desk. 

When the cramp has developed, rest is the most important aim. The 
patient should use the other hand or another holder; use other fingers, one 
of the appliances purposely arranged, or the typewriting machine. Massage, 
electricity, and exercises have cured some cases. In the other neuroses 
we should secure rest by using the other hand or other muscles and by gen- 
eral treatment as above mentioned. 

TETANY; PSEUDOTETANUS 

This is a subacute or chronic spasmodic disorder characterized by in- 
termittent or persistent tonic contractions, associated with paresthesia and 
overexcitability of the motor and sensory nerves. 

Etiology. — It is rare in this country. It occurs in infancy and child- 
hood, at puberty, and occasionally afterward up to fifty years. It oc- 
curs more often among males, and among the poorer classes. The excit- 
ing causes are exhausting influences, such as diarrhoea, lactation, sepsis, 
fatigue, mental shock, and fevers. Alcoholism, dilatation of the stomach, 
and intestinal parasites are causes. Extirpation of the thyreoid gland 
may be a cause. 

Symptoms. — Paroxysms of bilateral tonic spasm begin in the muscles 
of the hands, or of the hands and feet, after prodromal tingling and stiffness, 
and the spasm extends toward the trunk, which is involved in severe cases. 
The hands assume the obstetric position, the wrists and elbows slightly 
flexed, arms adducted, toes flexed, feet in the equino varus position, knees 
and hips extended or rarely flexed, and thighs adducted. The jaw is not 
affected until late, if at all. In the intervals, spasm may be excited by 
pressure on nerve trunks or arteries (Trousseau's symptoms) . The galvanic, 
faradic, and mechanical irritability of the affected muscles is enormously 
increased. 

Treatment. — Remove the cause if possible. Prescribe rest, nourishing 
food, and tonics. Symptomatically, give bromide of potassium, 5 jss. to 5ij 
daily, with chloral. Chloroform and morphine may be necessary. Luke- 
warm baths may be of service, also ice bags to the spine. Only weak 
galvanic currents should be used if electricity is tried at all. 

PARALYSIS AGITANS (SHAKING PALSY; PARKINSON'S DISEASE) 

This is a chronic progressive disorder with tremor, muscular rigidity, 
and weakness, and with a peculiar gait and attitude. There are also sensa- 
tions of heat, pain, and restlessness. 

^Etiology. — It is oftenest seen between fifty and sixty years of age. 
Exposure, hard labor, rheumatism, and rheumatoid arthritis seem to be 
predisposing causes. The exciting causes are fright, injury, and prolonged 
mental anxiety. Sciatica or rheumatism, sudden severe muscular strain, 
and fevers are rare causes. 

Symptoms. — The tremor begins after forty years of age, usually in one 
hand, rarely in one leg, and slowly extends to the other limb on the same 
side and then to the limbs on the other side. As a rule it may be lessened 



694 



THE NERVOUS SYSTEM 



or stopped by effort, but continues during rest. Rarely, in an early stage, 
it is elicited by effort. Following the tremor, beginning in the same part 
and spreading in the same order, muscular weakness and rigidity appear, 
the muscles, especially the flexors, gradually contracting so as to cause a 
characteristic posture with absence of facial expression. The hands assume 
the " pill rolling" position. There is a slight flexion of the knees, hips, 
wrists, elbows, and shoulders. The extensors may be involved. The head 
and spine are bent forward and the face stares straight ahead. The pa- 
tients are restless, uncomfortable, and unhappy and often have sensa- 
tions of heat and cold. The tendon reflexes are generally normal, rarely 
exaggerated. Nystagmus is not present. The speech becomes affected 
early. The voice becomes senile, high pitched and weak, and there is 
a slowness in starting to talk. A patient afflicted with paralysis agitans 
who is propelled forward or backward cannot stop at will. The rigidity 
increases, as does the tremor, and finally the patient becomes bedridden 
and dies of some intercurrent disease. The course averages from three to 
twelve years. 

Differential Diagnosis. — We have to distinguish this disease from senile 
tremor, multiple sclerosis, and posthemiplegic tremor. In senile tremor, 
the tremor is an intention tremor. The head is first affected. In mul- 
tiple sclerosis the tremor is more jerky, and there are nystagmus, syllabic 
speech, eye troubles, paralyses, and often apoplectoid attacks. Posthemi- 
plegic tremor has the history of hemiplegia; the disease is unilateral and 
there are paralyses and exaggerated reflexes. Alcoholic and hysterical 
tremors may be mistaken for paralysis agitans. 

The prognosis as to life is good, but bad as to a cure. Sometimes we 
may stop the increase in the symptoms. 

The 'pathological changes are not known. 

Treatment. — Physical and mental rest and fresh air should be advised, 
also lukewarm baths and mild massage. The galvanic current, daily em- 
ployed, gives temporary relief. Psychical treatment benefits some cases. 
For drugs, tonics of all kinds are used, and for antispasmodics, hyoscine 
hydrobromide, codeine, and morphine are used. 

OBSTINATE HICCOUGH 

Hiccough is looked upon as a reflex spasm of the diaphragm with simul- 
taneous closure of the glottis, the pneumogastric being the centripetal and 
the phrenic and recurrent laryngeal the centrifugal nerves involved. When 
associated with grave organic lesions, it may be of an obstinate type, but 
generally subsides on the application of one or more of the following pro- 
cedures if it is due to hysteria or gastrointestinal disorders: 1. Holding the 
breath for 15 or more seconds. 2. Hot applications over the cervical spine 
and diaphragmatic area. 3. Firm pressure upon the phrenic nerve over the 
scalenus anticus muscle. 4. Rapid swallowing of small pieces of ice. 5. The 
use of such antispasmodic drugs as morphine or chloroform. 6. Traction on 
the tongue, intermittently applied, as in chloroform poisoning. 7. Galvani- 
zation of the phrenic nerve. 8. Faradization of the epigastric region (Erb). 
9. Forcible elevation of the hyoid bone by the attendant's fingers (Noth- 



CEREBRAL APOPLEXY 



695 



nagel). 10. Taking snuff. 11. Applying a bandage tightly around the 
body. 12. Hypodermic injections of hydrochloride of pilocarpine. 13. 
Lavage of the stomach. 

DISTURBANCES WITH LOSS OF THE POWER OF MOTION 
PREDOMINATING (PALSIES, ACUTE AND CHRONIC) 

CEREBRAL APOPLEXY (HEMORRHAGE, EMBOLISM, AND THROMBOSIS) 

Cerebral apoplexy, to use the term in the restricted sense, is a sudden 
paralysis, usually with loss of consciousness, and is due to a rupture or 
occlusion of a blood vessel in the brain. We recognize two forms, intra- 
cranial haemorrhage, from rupture of a vessel, and acute softening, from 
thrombosis or embolism. 

Pathology. — The usual condition leading to apoplexy is chronic endar- 
teritis. This disease of the walls of the arteries tends to the obliteration 
of the lumen of the vessel, to fibrin deposits on the roughened wall producing 
thrombosis, to embolism in consequence of this deposit being washed onward, 
and to erosions and ruptures producing hsemorrhage. The kind of paralysis 
varies with the part of the brain in which this lesion takes place. 

etiology. — The age of liability to hsemorrhage is between forty- five and 
sixty-five. Males are more liable to hsemorrhage than females. The pre- 
disposing causes of endarteritis are gout, alcoholism, and syphilis, and ne- 
phritis, endocarditis, and emphysema are often associated. As an exciting 
cause of hsemorrhage we may include anything which increases the heart's 
action (heart strain), such as fright, anger, exertion, or a cold bath. Any- 
thing weakening the action of the heart may cause thrombosis. 

Symptoms. — Premonitory queer, dull, heavy feelings in the head, 
vertigo, insomnia, headache, inattention, imperfect memory, and tem- 
porary attacks of numbness in half of the body may occur for months 
before the onset. If we can rule out digestive disturbances, which produce 
practically the same symptoms, and kidney lesions, etc., we should look 
after the circulation, examine the arteries, and guard against the attack 
by advising avoidance of the exciting causes. 

The attack comes on suddenly, with unconsciousness usually, although 
in very light types there may be no unconsciousness or it may be slight. 
It is usual for paralysis of one half of the body (hemiplegia) to occur with 
coma and convulsions. The face is red; the pulse slow, full, and of high 
tension; the respirations deep and stertorous. The temperature may be 
subnormal or normal, but after some hours it may reach from 102° to 104°. 
The head may deviate to the side of the lesion. The pupils vary, but usually 
there is dilatation on the side of the lesion. There may be hemiplegia, 
hemianesthesia, and hemianopsia at first. The reflexes are at first inhibited, 
to become permanently exaggerated later. There is rigidity of limbs when 
the hsemorrhage is large, and convulsions are observed when it is on the 
cortex. The urine and fseces may be passed involuntarily, or the urine may 
be retained and may contain albumin and sugar. Death may occur in 
one or two days, in coma with high temperature. Usually there is slow 
recovery of consciousness ; the paralysis gradually improves for a year and 
then remains stationary. 
45 



696 



THE NERVOUS SYSTEM 



The symptoms, after a week, indicate the situation of the lesion, and 
those remaining at the end of a month indicate its extent. If contractures 
in the paralyzed limbs develop, they indicate descending degeneration in 
the motor tract. With the hemiplegia we observe flatness of the face on 
the paralyzed side; the muscles slightly draw it from this side; the eye 
can be closed and moved; the tongue deviates toward the paralyzed side; 
the finer motions of the hand and arm are more permanently affected than 
the elbow or shoulder motions; the upper extremity is carried in a flexed 
position ; the leg is stiff and extended and does not bend easily at the knee, 
and the foot is dragged on its inner edge and swung around in walking. 
The trunk and respiratory muscles are very rarely affected. The control 
of the bladder and rectum may not be complete. Hemianaesthesia and 
hemianopsia may remain without hemiplegia. The contractures develop- 
ing may cause pain. Aphasia of some kind may accompany a right sided 
hemiplegia, or it may occur alone. 

Mental affections sometimes appear and may remain as the only per- 
manent symptoms. The patient may not be able to control his emotions, 
so that he laughs or cries upon slight cause, shows irritability of temper, 
lack of judgment, imperfect memory of recent events, imperfect concen- 
tration of the mind, general bewilderment, not recognizing his surroundings 
or friends, mild delirium or delusions, or even dementia. These usually 
pass away. Epileptoid attacks may develop and recur at long intervals 
after an attack of apoplexy. 

Diagnosis. — Hemorrhage occurs after the age of fifty-five, as a rule, 
with atheromatous arteries and an hypertrophied heart. The onset is 
sudden, with coma, during exertion or excitement. The temperature falls 
in an hour, and then rises, sometimes to 106°. Gradual recovery of con- 
sciousness takes place in from three to five days, with permanent hemiplegia. 

Cerebral embolism comes on at any age, with heart disease or after 
childbirth. There is a sudden onset, without loss of consciousness or with 
slight mental confusion or with rapid return to consciousness. The tem- 
perature does not fall, but may rise as high as 102°. Improvement occurs 
within twenty-four hours to a marked degree, but after three or four days 
the symptoms return. Monoplegia, hemiplegia, or aphasia may remain. 
Jacksonian epilepsy may develop if the lesion is cortical, involving a special 
centre. 

Cerebral thrombosis occurs at any age, but chiefly in syphilitic persons 
and middle aged men. There are usually premonitions. The onset is 
slower, without coma, but with dulness of the mind. The temperature does 
not fall, but may rise to 100°. The paralysis is similar to that observed in 
embolism. 

The diagnosis between these three conditions is hardly ever positive. 
The prognosis depends upon the depth and duration of the coma, on the 
condition of the pulse and respiration, on the constitution and age of the 
patient, and on the number of previous attacks. 

Treatment. — In the stage of apoplexy we should employ rest, quiet, 
and an ice bag to the head; venesection in plethoric cases; and purgatives 
of a drastic nature. Stimulants should not be given unless the heart fails. 



OPHTHALMOPLEGIA 



697 



Care in feeding is necessary, on account of possible inability to swallow. 
The catheter should be used in urinary retention. Later, for the paralysis, 
we may try exercise, massage, vibration, and faradism to the muscles and 
iodide of potassium internally. 

BULBAR PARALYSIS (GLOSSOLABIOLARYNGEAL PARALYSIS) 

This is a rare disease characterized by a slowly progressing paralysis 
with atrophy in the motor cranial nerve nuclei. There is an acute form, 
differing only from the chronic by the suddenness of the onset. 

^Etiology. — There are small haemorrhages into the medulla in acute 
bulbar paralysis, and areas of softening following embolism or thrombosis. 
It is an acute inflammatory affection analogous to anterior poliomyelitis, 
or it may be due to a terminal lesion of Landry's paralysis. It is almost 
regularly bilateral. 

Symptoms. — There is disturbance of the speech — alalia (impaired articu- 
lation of the labial letters r, 1, d, and t); atrophy and tremor of the tongue 
occur, with paralysis; and chewing and swallowing are impaired. The 
muscles of lips and face become weak and thin, and we observe impairment 
in pronunciation of the labial letters p, b, v, and f, also atrophy and tremor 
of the lips with paralysis. Whistling is impossible and the facial expression 
is impaired. The saliva is increased and runs from the mouth. The action 
of the muscles of the pharynx and larynx is impaired ; food regurgitates or 
cannot be swallowed ; the reflex action is impaired and the larynx is therefore 
unprotected; the voice is low and monotonous; and it is impossible to cough. 
There is no change in the sensation of taste. The pulse is sometimes rapid, 
100 to 130. The duration is from two to five years. 

The differential diagnosis should be made from pseudobulbar paralysis 
of cerebral origin, where the lesion is in the lower portion of the third frontal 
convolution, and is not followed by atrophy. In myasthenia gravis no patho- 
logical changes have been found. Death occurs from inanition, aspiration 
pneumonia, or heart failure. 

Treatment. — When deglutition becomes impaired, we may feed the 
patient with the stomach tube. We may give large doses of strychnine 
early in the disease. 

OPHTHALMOPLEGIA 

Progressive ophthalmoplegia is a rare disease due to progressive atrophy 
of the nuclei of the motor nerves of the eye. According to which muscles 
are involved, there may be ophthalmoplegia externa or interna. Ophthalmo- 
plegia externa is the more common. There is a gradually increasing loss 
of power in all the muscles of the eyeball. We therefore observe ptosis, 
strabismus, nystagmus, immobility of the eyeball, and double vision. 
Ophthalmoplegia interna, exceedingly rare, causes loss of the reflex to light, 
and is a symptom in locomotor ataxia and general paresis. 

The diagnosis should be made from paralyses of the single nerves (the 
third or the sixth nerve) by the facts that such a paralysis is unilateral and 
that only the muscles supplied by that nerve are affected. 

Treatment. — If vibratory massage and iodide of potassium fail to im- 
prove matters, the case is hopeless. 



698 



THE NERVOUS SYSTEM 



Pressure palsies of cerebral origin, from the pressure of inflammatory 
products, such as tumors and abscesses, include acute pachymeningitis 
externa, acute pachymeningitis interna, chronic pachymeningitis interna, 
acute meningitis, chronic meningitis, and meningeal haemorrhage, which 
are described under the separate headings: Meningitis, Tumors, Abscess, 
and Brain Syphilis. For infantile cerebral paralysis and obstetrical paral- 
ysis see the section on Paediatrics. 

SPINAL APOPLEXY 

(Haemorrhage into the Spinal Cord — Haematomyelia, Intramedullary Haemorrhage) 

has been observed in tetanus, strychnine poisoning, and conditions leading 
to sudden asphyxia. It may complicate inflammation and tumors. It may 
be due to blows, falls, convulsions, or the haemorrhagic diathesis. 

Pathology. — The haemorrhage is usually situated in the central gray 
matter, and if large enough will be destructive in character. 

The symptoms are irritative and paralytic. 

The prognosis is not so good in intramedullary as in extramedullary 

haemorrhage. 

The treatment is symptomatic, in the hope that absorption may take 
place. 

ANTERIOR POLIOMYELITIS 

Anterior poliomyelitis in adults occurs more often in men than in women. 
The aetiology and pathology are the same as in children (see Paediatrics), 
except that the onset is less acute; the cranial nerves may be involved in 
some cases; rheumatoid pains may be present and are referred to the af- 
fected muscles and joints; muscular tenderness may be extreme; fewer 
muscles are affected and recovery is more complete; withering and retarded 
growth are not so noticeable. The treatment is symptomatic. 

Subacute Chronic Anterior Poliomyelitis. — ^Etiology. — The causes are 
falls and other injuries, alcoholic and sexual excesses, syphilis, and lead 
poisoning. 

Symptoms. — The onset is gradual, with motor weakness increasing to 
paralysis. The paralysis begins in the hand and spreads downward and 
upward. The paralyzed muscles undergo atrophy, and there is absence of 
the reflexes, with the reaction of degeneration. There is no sensory in- 
volvement, and the bladder and rectum are not involved. 

Prognosis. — Recovery is very rare. Usually there is a certain degree 
of improvement in a few weeks or months. Death may result from an 
extension of the disease to the medulla. 

The treatment is symptomatic. 

Anterior poliomyelitis in children (atrophic spinal paralysis) is described 
in the section on Paediatrics. 

SPINAL PROGRESSIVE MUSCULAR ATROPHY; WASTING PALSY (ARAN: 

DUCHENNE TYPE) 

The disease is most frequent in males between twenty-five and forty-five 
years old. An hereditary factor may rarely be present. Traumatism, 



PROGRESSIVE HEREDITARY MUSCULAR ATROPHY 



699 



acute infectious diseases, especially typhoid, measles, cholera, and acute 
rheumatism, syphilis, and, more than anything else, lead poisoning, are the 
causes. Puerperal infection may be an aetiological factor. 

Pathology. — The primary lesion is in the anterior horns of the spinal 
cord. 

Symptoms. — The disease begins gradually and insidiously in the fingers 
and interossei muscles and travels upward and downward. There are slight 
rheumatoid pains in the shoulder or arm. The muscles tire easily and be- 
come less firm. Muscular atrophy usually appears first in one hand, in 
the interossei and the ball of the thumb. The atrophy spreads from muscle 
to muscle. Motor weakness is proportionate to the atrophy, and there is 
no essential paralysis. The hand assumes the characteristic appearance, 
"main en griffe." In a few cases the deltoid is affected first, and the 
atrophy descends, constituting the " upper arm " type. In from three to 
nine months the other arm begins to be affected. In rare cases the atrophy 
may begin in the lumbar or abdominal muscles of the legs, and ascend 
(perineal type). 

The atrophied muscles are flaccid and usually retain their normal elec- 
trical reactions (differential factor between chronic anterior poliomyelitis 
and amyotrophic lateral sclerosis, in which there is a spastic condition with 
rigid muscles). The reflexes are diminished according to the amount of 
atrophy. Fibrillary twitchings occur. When the lumbar muscles are im- 
plicated, the back is arched and the line of gravity falls behind the sacrum. 
When the abdominal muscles are affected, the back is arched, but the line of 
gravity falls in front of the sacrum. In time, all the voluntary muscles may 
be involved. The face muscles are normal, but the body is greatly wasted. 
Ophthalmoplegia externa and bulbar paralysis may develop toward the 
close of the disease. 

Prognosis. — The course is usually progressive. Death may come from 
exhaustion, bulbar paralysis, or respiratory affections. The patient may 
live for years, the disease becoming quiescent. 

The treatment does no permanent good and is symptomatic only. Io- 
dide of potassium is indicated. 

PROGRESSIVE HEREDITARY MUSCULAR ATROPHY, PERINEAL 
(CHARCOT-MARIE) TYPE 

This is an hereditary, or family, muscular atrophy beginning in the legs 
and extending upward. It is not known whether it is central or peripheral 
in origin. Almost always it begins before the age of twenty, and affects 
males oftener than females. First the muscles of the leg, then the extensors 
of the toes, and then the calf muscles are affected. Later the thigh muscles, 
and after some years the muscles of the forearm and hand are reached. 
The shoulder, arm, neck, and trunk muscles escape. Fibrillary contractions 
are occasionally present, and there is always a partial or complete reaction 
of degeneration. The disease continues for years, with remissions, and 
although it is not curable, the prognosis is better than in the arm type. 

The treatment is the same as that in other forms of hereditary muscular 
atrophy. 



700 



THE NERVOUS SYSTEM 



AMYOTROPHIC LATERAL SCLEROSIS 

This is really a form of progressive muscular atrophy, with the same 
aetiology, differing by showing spastic symptoms and paralysis. 

The symptoms result from a combination of progressive muscular atrophy 
and lateral sclerosis. Wasting, weakness, rigidity, contractures, and ex- 
aggerated reflexes develop. Atrophy and weakness are especially marked 
in the arms and hands, while in the legs the spastic paraplegia develops early. 
Muscular fibrillary twitchings are usual. The bladder and rectum are con- 
trolled, and there are no sensory symptoms. Rigidity and muscular wasting 
become general, and paralysis results. Symptoms of bulbar paralysis and 
ophthalmoplegia externa make their appearance. 

The prognosis is not so good as in progressive muscular atrophy. The 
disease is seldom if ever arrested, and death results in from one to four years. 

Treatment gives no satisfactory results. 

LATERAL SCLEROSIS 

Lateral sclerosis (spastic spinal paralysis) is a chronic sclerotic process 
affecting the lateral pyramidal columns of the spinal cord. If it is a primary 
disease, which is exceedingly rare, it is bilateral. 

Differential Diagnosis from Anterior Poliomyelitis (Starr) 



Lateral Sclerosi 

1. Lesion in pyramidal tracts. 

2. Paralysis usually on both sides 

equally, in legs or in legs and 
arms, never in arms alone. 

3. All muscles are about equally 

affected. No muscles entirely 
normal. 

4. Muscular tone heightened. 

5. Tendency to rigidity. 

6. Reflex excitability increased. 

7. Atrophy absent or slight ; merely 

due to disease, gradual in 
progress, affects entire limb. 

8. Electric contractility unchanged. 

9. Vascular tone diminished; cya- 

nosis and cedema may occur. 

10. Paralyzed limb is cold; sweat 

may be increased. 

11. Trophic disturbances of skin are 

not infrequent. 

12. Control over bladder and rectum 

impaired or lost. 



Anterior Poliomyelitis 

1. In anterior gray horns. 

2. Paralysis may be limited to any 

single limb, rarely affects 
both limbs equally. 

3. Certain groups only of muscles 

are affected. Others escape 
wholly. 

4. Diminished. 

5. Relaxation. 

6. Lost. 

7. Always present in paralyzed 

muscles; advances rapidly; 
may become extreme. 

8. R. D. present within two weeks 

of onset. 

9. Vascular tone diminished, but 

oedema not present. 

10. Paralyzed limb cool; sweat not 

increased. 

11. Not present. 

12. Not impaired. 



LOCOMOTOR ATAXIA 



701 



Secondary lateral sclerosis is the most frequent form of spastic paraplegia, 
and results from any lesion in which the central motor neurone is involved. 
These lesions may be: Tumors, softening, or haemorrhage in the brain; 
congenital maldevelopment of the brain and hydrocephalus; or a cord 
lesion, unilateral or bilateral, or compression of the cord by disease of the 
vertebras or myelitis and meningomyelitis. 

Symptoms. — Idiopathic spastic paraplegia shows a weakness and stiff- 
ness in motion, beginning in the legs and ascending, and finally involving 
the arms. Atrophy is not present. Reflex and mechanical excitability 
is increased, causing increased knee jerk and the presence of ankle clonus. 
There is rigidity from increased spinal activity, making the gait character- 
istic. This is at first spastic; the toes drag, the knees overlap, motion is 
stiff, and finally, in complete paralysis, the legs are drawn up, the knees 
overlap, and are so rigid that the patient cannot move them. The muscles 
show no degeneration reaction. 

There is, late in the disease, impairment in the control of the bladder, 
which finally results in paralysis with involuntary emptying or with 
retention. Constipation is obstinate. The bladder and rectum are not 
affected in some cases of primary sclerosis. No sensory symptoms are 
present. Nutrition is impaired and the vascular tone is diminished toward 
the end of the disease, causing blueness and coldness. Death is rare from 
this disease by itself. The symptoms develop slowly and increase until, 
after many years, permanent paralysis develops. 

LOCOMOTOR ATAXIA (TABES DORSALIS; POSTERIOR SPINAL SCLEROSIS) 

^Etiology. — Males are affected with this disease about ten times as often 
as females. It is most common between the ages of thirty and fifty. Syph- 
ilis precedes the disease in over 90 per cent of the cases. 

Pathology. — Briefly, it may be stated that there is a degeneration of 
the posterior roots of the dorsal columns of the cord. Sometimes the spinal 
ganglia and peripheral nerves are affected. 

The symptoms are usually divided into four stages: the stage of pain, 
loss of tendon reflex, the stage of ataxia, and the stage of paralysis. 

Stage op Pain and Loss of Tendon Reflex. — Pain occurs in 90 per 
cent of the cases. It is of a paroxysmal, darting character, bilateral, extend- 
ing down the legs, and generally referred to the deeper structures. The pains 
are lightninglike in character, irregular in distribution, seldom or never 
corresponding to nerve trunks, and there is no local tenderness. Sometimes 
the pain is diffused and superficial, and the patient may have a sensation 
of extreme heat or cold. When the lesion extends to the cervical region 
of the cord, there may be lightning pains in the arms. In a few cases where 
optic atrophy is one of the first symptoms the pain may be absent or slight. 
In these cases the ataxia is not apt to develop. Occasionally there are 
trophic disturbances. 

Parcesthesice. — In this pain stage there are sensations of numbness, 
formication, dead extremities, cotton or pins in the soles of the feet and the 
fingers, coldness, and itching of the anus, scrotum, and other parts. There 
is a sensation of tightness or pressure around the waist, the girdle sensation, 
which ascends gradually as the disease advances. 



702 



THE NERVOUS SYSTEM 



Westphal's symptom, loss of the knee jerk, is one of the earliest symp- 
toms and one which is seldom absent. If it is associated with lightning 
pains and the ocular symptoms, we have a symptom group absolutely diag- 
nostic of locomotor ataxia. 

Bladder and Rectum Symptoms. — There is imperfect control of the blad- 
der. There is slow urination, with slight dribbling, or hasty urination may 
be seen. Later, the control is very imperfect and micturition may be very 
painful. Cystitis may occur and it may be a serious symptom, as it some- 
times results fatally. Impotence is usual, but previously there may be 
priapism and disordered sexual excitement. Constipation is usually ob- 
stinate. 

Eye Symptoms. — There may be ptosis, strabismus, double vision, or in 
rare cases ophthalmoplegia externa. The Argyll Robertson pupil, a symp- 
tom present in this stage in 80 per cent of the cases, is the loss of the pupillary 
reflex to light, the reaction in accommodation being preserved. Contracted 
pupil, " meiosis spinalis," is frequent but not constant. 

Stage of Ataxia, Anaesthesia, and Analgesia. — The sense of pain is 
impaired and delayed, which prevents the knowledge of injuries received, so 
that such symptoms as ulcer of the foot and Charcot's joints occur as com- 
plications. We should guard against accidents and neglect of injuries, as 
in giving hot baths, etc. 

Hyperalgesia. — The sensation of pain may be severe simply from a 
touch. There is a change in the sensation of temperature, cold being felt 
keenly and heat less than normal. Late in the disease, there is a develop- 
ment of complete anaesthesia in the extremities. 

Impairment of Muscular Sense. — The situation of the limbs is imper- 
fectly perceived, so that, as it is normally a means of perfect guidance, its 
absence causes the patient to walk badly in the dark, to be unable to touch 
objects accurately with the eyes closed, and to watch his own motions, aiding 
his muscular sense by sight. A blind ataxic is a most helpless person. 
Ataxia, or imperfect coordination of muscular action, is a prominent symp- 
tom. The ataxic gait is that in which the legs are held too far apart, the 
feet are lifted too high and put down too forcibly, the steps are of irregular 
length, and the body is imperfectly balanced. The hands cannot be per- 
fectly controlled, as in writing, dressing, and the finer movements. There 
is an irregular contraction of the muscles and there is imperfect tone in them. 
To test the ataxia, we ask the patient to stand with his eyes closed and walk, 
turn suddenly or walk backward, to touch the heel to the toe or the heel 
to the knee, to touch the finger to the nose, to pick up a pin, etc. 

Symptoms occasionally present are those due to neuritis of different 
nerves. Progressive blindness due to atrophy of the optic nerve is present in 
about 20 per cent of the cases. Paralysis of the third cranial nerve causes 
divergent strabismus, with dilated pupils and ptosis. Nystagmus rarely 
occurs. Paralysis of the sixth nerve causes convergent strabismus with 
contracted pupils. Atrophy of the auditory nerve gives rise to deafness. 

Crises. — 1. Gastric crises, sudden vomiting with pain, may occur at 
intervals lasting from several hours to several days. It is followed by great 
prostration, and may make nutrient enemata necessary. Intestinal and 
rectal crises with diarrhoea and tenesmus are rarely seen. 



LOCOMOTOR ATAXIA 



703 



2. Laryngeal Crises. — Sudden severe cough with spasm of the larynx 
and suffocation. 

3. Cardiac Crises. — Attacks of angina pectoris are rare. These symp- 
toms are all due to a complicating neuritis of the pneumogastric nerve, 
and are not very common. In this stage, trophic disturbances are more 
common. 

Charcot joints at the knee, elbow, ankle, and wrist. There are swelling 
and effusion without pain. There may be erosion of the ends of the bones 
and destruction of the articulation. Injury precedes these joint lesions 
(see section on Joint Diseases). Perforating ulcer of the foot may develop from 
neglect of a corn, a subcutaneous haemorrhage, or caries of bone. Rare- 
faction of bones, with spontaneous fractures, may occur. Irregular muscular 
atrophies may develop late in the disease. Herpetic eruptions and pemphi- 
gus may occur. These symptoms are largely due to a loss of the sensation 
of pain, which prevents knowledge of injuries, or to a peripheral neuritis. 

Stage of Paralysis. — Although the general nutrition remains good, the 
ataxia becomes so bad as to make the patient helpless, and he is obliged to 
keep to his bed. The control of the rectum and bladder is lost, the urine 
dribbling constantly. The trophic disturbances are more marked, and also 
injuries from accidents. Patients die from exhaustion, or complicating 
pneumonia. Fatal asphyxia may result from a larjmgeal crisis or aspira- 
tion pneumonia due to anaesthesia of the larynx. 

Prognosis. — The disease is chronic and lasts from twenty to forty years. 
Ataxia is rarely developed until from five to eight years after the begin- 
ning of the disease. Recovery never occurs, but arrest of the disease may 
take place at any time, particularly during the first stage. 

Modes of Onset. — The most usual beginning is with pain, loss of knee 
jerk, bladder trouble, impotence, and ataxia. Occasionally it may begin 
with blindness, loss of the knee jerk, imperfect gait, and numbness, but no 
pain; or with gastric crises, at intervals, loss of the knee jerk, and then 
pain and ataxia; or with various forms of strabismus, meiosis, and then 
ataxia of the arms. 

The diagnosis is made early by means of the pains, fatigue, loss of the 
knee jerk, and the Argyll Robertson pupil. Later we make it from the 
presence of ataxia and bladder trouble. Multiple neuritis is sometimes 
confounded with tabes, but its onset is rapid, paralysis occurs early, control 
of the bladder is present, and there is no Argyll Robertson pupil. 

Treatment. — There should be ordered moderate exercise, but avoidance 
of all fatigue. The diet should be full and good. Douches over the spine 
of tepid or cool water (never at extremes of temperature) are helpful. The 
patient should have massage and try to overcome the ataxia by practising 
fine movements. An inunction course or mercury and potassium iodide may 
be tried. The pain may be treated with the coal tar products, gelsemium, 
opium, faradization, and hot applications; the crises with counterirritation 
and morphine. Care should be observed not to injure the patient by coun- 
terirritation or hot applications, as trophic disturbances are likely to follow. 
Optic nerve atrophy should be treated with strychnine. The trophic dis- 
turbances are best met with rest and apparatus. 



704 



THE NERVOUS SYSTEM 



Hereditary Ataxia {Friedreich's Ataxia) 
Although this is not necessarily an hereditary disease, it is really a 
family disease, as several brothers and sisters may be affected. When it 
is hereditary, there is usually a family history of some nervous disorder — 
insanity, inebriety, or nervous irritability. It is apt to appear between the 
fifth and fifteenth years. 

Pathology. — There is sclerosis of the posterior and lateral columns of 
the spinal cord, which may extend upward. 

Symptoms. — The ataxia begins in the legs, but it is different from that 
of locomotor ataxia, for the gait is more swaying and irregular and there 
is less stamping. Romberg's symptom is sometimes present. The deep 
reflexes are lost early. Later, ataxia develops in the arms, causing chorei- 
form movements, which may be observed during rest. Nystagmus and a 
slow, scanning speech are commonly observed. Optic atrophy and visceral 
symptoms are uncommon. Trophic changes are not observed. There is 
a fairly characteristic deformity of the foot. The patient walks on the outer 
edge of the foot, with the big toe flexed dorsally upon the first phalanx. 
Talipes equinus develops. There are no sensory symptoms. Late in the 
disease the mind becomes impaired, and paralysis appears, which may 
become complete. The affection is incurable and extends over many years. 
Care should be taken to prevent contractures. There is no effective treat- 
ment. 

ATAXIC PARAPLEGIA (COMBINED SCLEROSIS) 
This is a disease developing in males of middle age and characterized 
by a combination of ataxia and paraplegia. There may be a history of 
infection or of sexual excesses, but a history of syphilis is seldom to be ob- 
tained. 

Pathology. — There is a combined sclerosis of the posterior and lateral 
columns of the cord, beginning in the lumbar region. The nerve roots are 
not involved, as in locomotor ataxia. 

Symptoms. — Slowly developing weakness of the legs occurs, with rigidity 
and ataxia. The knee jerk is exaggerated, and the ankle clonus can be 
elicited. Romberg's symptom is generally well marked, developing later, 
but eye symptoms are rare. For sensory symptoms we observe usually 
only a dull aching pain in the sacral region, etc. The ataxia and weakness 
may extend to the arms. Finally paralysis and failure to control the 
sphincters develop. Mental symptoms, similar to those in general paresis, 
may develop. 

Diagnosis. — From the combination of marked incoordination with more 
or less spasm and presence of the reflexes, the diagnosis is easy. The ab- 
sence of ocular and sensory symptoms is an important point. It is, in 
short, a motor weakness, with symptoms of tabes. 

Prognosis. — The disease is incurable. Death results from complications. 

The treatment is symptomatic. 

MYELITIS 

Myelitis is a disseminated inflammation, or it may involve an entire 
segment of the cord, both gray and white matter. 



MYELITIS 



705 



Pathology. — The cord has a normal appearance, but is soft at points. 
It may be soft enough to be fluid. The gray matter looks red, and capillary 
haemorrhages are seen. There are marked microscopical changes. 

etiology. — Infection, injury, disease of the vertebrse, or tumors, caus- 
ing compression or destruction of the cord, are among the causes. It 
may result from acute infectious diseases, especially smallpox, measles, 
and typhus fever. It may follow the primary lesion of syphilis within a 
year or eighteen months, and the growth of gummata may be the cause of 
compression. Chronic alcoholism is mentioned as a cause. Males are more 
often affected than females, particularly soldiers and porters. 

Varieties. — We speak of acute, subacute, and chronic cases. Also, accord- 
ing to the amount of cord tissue diseased and the situation, we speak of 
general myelitis, where the entire cord is affected, ascending or descending; 
disseminated myelitis, where various segments at different levels are affected; 
and transverse myelitis, where one or two segments at one level are affected. 

Symptoms. — Direct symptoms result from destruction of tissue in the 
cord. According to the situation of the lesion in the cord do we observe 
the distribution of direct symptoms. General myelitis gives rise to univer- 
sal symptoms, disseminated myelitis causes scattered symptoms, and trans- 
verse myelitis limits them to one level. The motor symptoms are paralysis, 
atrophy, loss of muscular tone, and the reaction of degeneration. The 
reflex symptoms, according to the situation of the lesion, are paralysis of 
the bladder and rectum, and impotence. The sensory symptoms are numb- 
ness, anesthesia, paresthesia, hyperesthesia, and pain. The back is tender 
to heat sensations. The vasomotor and trophic symptoms are bedsores, 
profuse sweating, and imperfect circulation with coldness of the skin. A 
knowledge of the spinal nerves and their distribution is necessary to ascer- 
tain the level of the disease in the cord. 

Indirect symptoms are due to the interruption of the impulses normally 
passing through the cord. Below the lesion there is paralysis, with increased 
reflexes, muscular rigidity, and contractures. The paralyzed muscles do 
not undergo atrophy. There is no reaction of degeneration. The bladder 
is usually not paralyzed, but there is loss of control, with priapism. Although 
there is imperfect sensation, coordination remains intact. The anesthesia 
permits of the formation of bedsores over the sacrum, glutei, heels, and 
ankles. There is moderate fever. 

Course. — General myelitis and disseminated myelitis may be acute or 
subacute in their onset. The disease begins with weakness of the limbs, 
pains in the back and limbs, and prostration, and then there follow paralysis, 
pain and anesthesia, and bladder and rectal symptoms, with confinement 
in bed and the development of bedsores. The course is slow, from one to 
three years. Occasionally there is a slow imperfect recovery. Usually 
death takes place from cystitis, or pneumonia. Transverse myelitis, 
when acute, may rarely develop in two days. It comes after an in- 
jury, blow, fall, wounds, dislocation of the spine, or a strain, which cause a 
hemorrhage in the cord. It may arise from an embolus of a spinal artery. 
Its course is chronic after spinal caries with deformity and pressure, or 
after a tumor in the spinal cord or canal. The length of its course depends 
upon the possibility of removing the cause. 



706 



THE NERVOUS SYSTEM 



The diagnosis of myelitis is rarely difficult. Landry's paralysis and some 
cases of multiple neuritis and meningitis show similarities. Landry's 
paralysis shows very slight sensory disturbances, no trophic symptoms, 
very seldom bladder and rectum paralyses, and no electrical changes. 

In multiple neuritis the sensory symptoms are marked, but there is 
rarely if ever complete anaesthesia, there is no affection of the bladder and 
rectum, there are no bedsores, there is no oversensitiveness of the spine to 
heat, and the distribution of the symptoms is peripheral. 

In meningitis the onset is slower, the fever is high, and the pain in 
the back, body, and limbs and the hyperesthesia are severe; there is 
no anaesthesia, but there are early spasms of the limbs and back, with 
rigidity of the back; there is only apparent paralysis, due to fear of pain 
on emotion, no atrophy, no paralysis of the sphincters, no bedsores, and 
no cystitis. 

Treatment. — In the early stages, try to remove the cause. Have the 
patient lie on the side or face, and cup the spine or apply an ice bag, counter- 
irritation, or a warm douche. Give sedatives, and purge thoroughly with 
calomel and salts. When the onset is gradual or the course is chronic, use 
counterirritation to the spine, cups, blisters, and the cautery or ether spray, 
but not if there is a tendency to bedsores. Baths and douches, tepid or cold, 
may be used over the spine. The limbs should be massaged and hot baths 
be given for rigidity. Electricity, vibration, and massage may be used to 
exercise the muscles. The diet should be regulated, and the general strength 
kept up as well as possible. Avoid cystitis by aseptic catheterism, and bed- 
sores by careful padding or the use of a water bed, and by sponging with 
alcohol and alum water. If cystitis or bedsores develop, treat them sur- 
gically with antiseptic irrigation and dressings. 

For the -pain, use heat or the faradic brush. Give antipyrine, acetanilide, 
phenacetin, bromides, morphine, or salicylic acid. For the spasms, we may 
give bromides and apply heat to the spine or cups or hot baths to the legs. 
If rigidity appears, we may use mechanical appliances and massage. For 
incontinence of urine, have a urinal worn, or absorb the urine in cotton. 

In the chronic cases we may use potassium iodide, strychnine, arsenic, 
and phosphorus. In the syphilitic cases we should use large doses of mercury 
and potassium iodide or an inunction course. 

ACUTE ASCENDING PARALYSIS (LANDRY'S PARALYSIS) 

^Etiology. — This form of paralysis is due to infection. It is most common 
in men between the ages of twenty and thirty. 

Pathology. — In some cases no lesions have been found. In others an 
interstitial neuritis of the nerve roots has caused it to be classified as a 
peripheral neuritis. 

Symptoms. — At first there is a weakness of the legs, which may in a 
few hours merge into paralysis. This spreads to the trunk, arms, and neck. 
The muscles of respiration, deglutition, and articulation, and sometimes 
those of the face and eyes, are affected in a few days. Although the muscles 
show no wasting or the electrical reaction of degeneration, the reflexes are 
lost. The sensory symptoms are neither constant nor essential, but there 



CEREBROSPINAL SCLEROSIS 



707 



may be numbness, tingling, or hyperesthesia. The bladder and rectum 
are seldom involved. The spleen is sometimes enlarged. 

The prognosis is bad; recovery has taken place only in rare instances. 
Death may occur in from two days to two weeks. 

Treatment. — After a brisk purge we give warm baths and administer 
sodium salicylate, in 10 to 20 grain doses in water per rectum, three times 
a day. Sedatives and stimulants may be required. 

SYRINGOMYELIA 

Syringomyelia is not a very rare disease. It is probably of congenital 
origin, but it may follow traumatism. It is more common in males before 
the age of thirty. 

Pathology. — A growth of embryonal neuralgia tissue about the central 
canal of the cord degenerates and forms a cavity filled with fluid. It 
usually is in the lower cervical and upper dorsal region, but may extend 
the entire length. According to the degree of extension we observe the 
symptoms. 

The symptoms begin insidiously at about puberty and extend for years. 
Aching pains in the neck and arms are followed by muscular atrophy, 
first in the hands, then in the arms and trunk. The loss of sensations of 
temperature and pain, while those of touch and location are retained, is 
almost pathognomonic. The legs become involved late in the disease 
and show a spastic paraplegia. Curvature of the spine usually results 
from involvement of the spinal muscles. Cyanosis, cedema, sweating, 
ulcers, bullae, defective growth of the nails, and brittleness of the bones 
result from the vasomotor, secretory, and trophic disturbances. Felons 
may arise. If the lumbar cord is involved, there is loss of control of 
the sphincters. 

Diagnosis. — We distinguish the disease by the sensory pathognomonic 
signs (loss of the senses of temperature and of pain, retained touch and 
location sensations) and the combination of an amyotrophic paralysis, 
and progressive muscular atrophy of the Aran-Duchenne type. 

The prognosis is bad. The disease extends over years. In the later 
stages the disease resembles chronic muscular atrophy. Death may result 
from involvement of the medulla. 

The treatment is symptomatic. It is important, then, to warn patients 
suffering from beginning syringomyelia of the necessity of taking the greatest 
possible care of the affected member, in order to avoid the accidents to 
which it is liable because of the disturbed sensory condition of the part. 

CEREBROSPINAL SCLEROSIS (MULTIPLE OR DISSEMINATED SCLEROSIS) 

This is a rare chronic disease, affecting the brain and spinal cord together. 

Pathology. — There are regions scattered throughout the entire nervous 
system where sclerotic connective tissue replaces the normal nerve elements. 

^Etiology. — The cause is obscure. It regularly is a sequel of the infec- 
tious diseases, measles and scarlet fever in particular, and is found most 
frequently in young persons. 



708 



THE NERVOUS SYSTEM 



Symptoms. — The onset is slow and the disease is chronic. Headache, 
vertigo, malaise, mental irritability, inattention, imperfect memory, lack 
of self-control, and inability to work gradually develop. Later there de- 
velops a tremor of the hands, increased by the effort to hold them still, and 
finally there is a general intention tremor. The legs early become weak 
and stiff, and finally a spastic gait develops. The knee jerk is increased. 
Nystagmus and "scanning speech " (slow, each word separately enunciated 
without variation in tone) are observed. Optic atrophy is rare. Dementia, 
attacks of epilepsy, and hemiplegia may finally occur. 

The course is very irregular, and the symptoms may disappear for 
months and then return. The patient dies from some other disease or 
finally becomes bedridden. 

The diagnosis is made from the intention tremor, scanning speech, and 
nystagmus. The reflexes are exaggerated. 

Treatment. — None seems to prevent the progress of the disease. 

DIVERS' PARALYSIS (CAISSON DISEASE) 

Persons who work in diving-bells or under increased atmospheric pres- 
sure are likely to have this disease if they emerge suddenly into the normal 
atmosphere. The longer they remain in the caisson, and the more suddenly 
they return to the normal atmosphere, the more likely they are to have the 
disease. Those unaccustomed to the work are most likely to be attacked. 

Pathology. — Small haemorrhages are found in various localities of the 
body, together with emboli of free gas in the circulation. 

The symptoms may appear at once or may not occur for half an hour 
after leaving the caisson. Usually there are very severe pains in the limbs, 
the legs are tender to the touch, and there is some loss of motor power. 
Epigastric pain, nausea, vomiting, headache, and dizziness are likely to 
occur. Paralysis and anaesthesia may rapidly develop in the legs, although 
the neuralgic pains continue. A temporary loss of consciousness some- 
times occurs. 

Prognosis. — Convalescence may take place in a few days or be delayed 
for months, with continuous suffering and paralysis. In severe cases the 
patient may pass into coma and die in a few hours or days. Atrophic bed- 
sores and cystitis sometimes develop. Permanent paraplegia is occasionally 
a result. 

Treatment. — The prophylaxis consists in allowing sufficient time for pass- 
ing through the lock, where the pressure is reduced. At least five minutes 
should be allowed for each atmosphere. The workmen should be gradually 
accustomed to the occupation, and the hours should at first be short. If 
the symptoms begin, the patient should immediately be put back under a 
slight atmospheric pressure. 

In the acute stages ergot in large doses seems to be of service. In the 
paralytic stage the treatment is the same as in myelitis. 

CRANIAL NERVE PALSIES 
Disease of the third nerve or pressure upon it gives rise to external 
strabismus, ptosis, dilatation of the pupil, loss of the pupil reflex and of 



FACIAL (SEVENTH NERVE) PALSY (BELL'S PALSY) 



709 



accommodation to distance, and diplopia. The paralysis may be due to a 
neuritis, especially one associated with locomotor ataxia, and may follow 
diphtheria or may be due to pressure from the exudate of a meningitis, 
tumor, or aneurysm, or to rheumatism, syphilis, or to an attack of migraine. 
The excessive use of tobacco is also a cause. 

The course is usually subacute, lasting for a few weeks. Functional 
palsies last only a few days, and the periodical palsies occur once in a year 
or six months. The latter are accompanied with some pain at first, and 
last a few days or weeks. Syphilitic palsies last from one to three weeks, 
but are apt to relapse and to be very obstinate. 

Treatment. — Treat the underlying cause and apply faradism, galvanism, 
and vibration. 

A fourth nerve palsy is rare. Convergent strabismus and diplopia result. 
The causes are the same as those of third nerve palsies. 

Fifth Nerve Palsies. — These may be nuclear, central, meningeal, or per- 
ipheral in origin. Those of central origin usually accompany hemiplegia. 
Palsy of nuclear origin is rare. It usually accompanies glossolabial or 
diphtheritic palsy or some gross lesion of the pons. When it is of menin- 
geal origin, from tumors, meningitis, or fracture at the base of the skull, 
it is usually accompanied by lesions of the other cranial nerves. Syphilis 
is often the cause. The temporal and masseter muscles are paralyzed 
and the jaw, when depressed, moves toward the paralyzed side. Both 
speech and swallowing are interfered with. Through a little branch of the 
fifth nerve passing to the tensor tympani, we may get deafness and tinnitus 
aurium, when the fifth nerve is affected. 

Sixth nerve palsy is the most frequent, and it causes convergent strabis- 
mus and diplopia. Locomotor ataxia and syphilis are most often associated 
with this form of palsy. 

Facial (Seventh Nerve) Palsy (Bell's Palsy). — This common type of 
peripheral paralysis is usually due to exposure and rheumatic infection. 
It occurs most often between the ages of twenty and forty, and in males. 
Winter is the season in which we find it most often. A neuropathic or 
rheumatic tendency predisposes to it. In syphilis we rarely observe a 
facial paralysis. It may occur in multiple neuritis and locomotor ataxia. 
Some cases, not typical, however, are due to injuries (such as fracture of 
the petrous portion of the temporal bone) or ear disease. The use of the 
forceps in labor has caused some cases and a few have been congenital. 

Symptoms. — The disease comes on suddenly and reaches its height 
within a few hours or at most within two or three days. Some pain and 
swelling around the ear may precede it. The appearance of the face is 
characteristic. On the affected side there are no wrinkles, the angle of the 
mouth is lower, and the mouth is drawn toward the sound side. Owing to 
this, it looks as if the tongue could not be protruded straight. In trying to 
wrinkle the face, as in laughing or showing the teeth or making a grimace, 
the paralysis is distinctly shown. The eye on the palsied side cannot be 
perfectly closed, and the eyeball turns up. The eye is likely to be watery 
and the conjunctiva somewhat injected. The nostril on the paralyzed side 
does not expand on forced inspiration. If the disease extends into the 
Fallopian canal, paralyzing the stapedius muscle, there is oversensitiveness 



710 



THE NERVOUS SYSTEM 



to sounds. By noting the ear and taste involvements, the situation of the 
lesion can be accurately determined. Some wasting of the face may usually 
be made out after a few weeks. 

There are great variations in the electrical reactions, which are in pro- 
portion to the severity of the case. Typical or partial degeneration re- 
actions can usually be observed. The patient feels a subjective dis- 
comfort on the paralyzed side. He cannot pucker the lips or close the 
eye on that side. In chewing, the food gets between the cheek and 
teeth. The speech is slightly muffled. . Secondary contractures begin to 
appear if the disease lasts for two months or more, and the mouth is 
drawn toward the affected side. The nasolabial fold becomes deeper than 
on the sound side. 

Pathology. — In its typical form, the disease is due to a diffuse neu- 
ritis of rheumatic character. 

Diagnosis. — By asking the patient to make a grimace we get the char- 
acteristic expression. It is important to find out whether the palsy is 
cerebral, nuclear, basilar, or peripheral. If it is cerebral in origin, the upper 
branch is little affected and the patient can close his eye. There is no 
reaction of degeneration. 

Nuclear palsy is very rare. There are other symptoms, especially 
those of the involvement of other cranial nerves. A history of diphtheria, 
lead poisoning, or bulbar paralysis can usually be obtained. If it is 
basilar in origin, such as is due to a gummy meningitis, there are signs of 
brain syphilis and the involvement of other cranial nerves. Most cases 
are peripheral in origin. 

The prognosis of Bell's palsy is good, although often there is not com- 
plete recovery. If it is syphilitic in origin, the prognosis is good. If it is 
of central origin, the prognosis is not good. The paralysis of peripheral 
origin usually lasts from three to five months, but very mild cases become 
normal in a month. According to the completeness of the reaction of de- 
generation is the prognosis as to duration. 

Treatment. — Acute peripheral palsies demand prompt purging and 
diuresis and a blister over the exit of the nerve. Hot fomentations may 
follow. Salicylate of sodium in full doses should be given for a week. 
After the paralysis is established, give potassium iodide in moderate 
doses. Electricity should be used carefully at first. After a week, give 
it daily for five minutes, and use the galvanic current, just strong enough 
to contract the muscles. Vibratory massage is efficacious. If after a 
time the faradic current causes a contraction, it may be used. After a 
month, the applications can be made on alternate days. If the paralysis 
is severe, a mechanical device may be used daring the day to hold up the 
corner of the mouth, such as a hook fastened behind the ear. The eye 
should be protected. 

Glossopharyngeal (ninth nerve) paralysis is described under Paralyses 
of Central Origin (Glossolabiolaryngeal Paralysis). 

Pneumogastric (tenth) Nerve Paralyses. — The nucleus may be involved 
by haemorrhage, tumor, softening, or slow degeneration. In bulbar paral- 
ysis the nucleus of this nerve is involved. The nerve root may also be 
involved within the cranium. In the neck, the pneumogastric may be in- 



NEURITIS 



711 



jured by wounds or accidentally during operations. As there are branches 
to the pharynx, larynx, lungs, heart, oesophagus, and stomach, we shall 
speak of these branches separately. 

1. A paralysis of the pharyngeal branches, from bulbar degeneration, 
or a post diphtheritic neuritis causes difficulty in swallowing and permits 
food to enter the larynx or, if the soft palate is also involved, to be re- 
gurgitated through the nose. 

2. A paralysis of the laryngeal branches may cause a variety of symp- 
toms, which are described in the section on the Throat. 

3. A lesion of the pulmonary branches is supposed to exist in the shape 
of a neurosis, when there is bronchial asthma. 

4. Paralysis of the cardiac branches abolishes the inhibitory action, 
and we observe tachycardia. It may occur with a diphtheritic neuritis, 
wounds, or accidental injuries of the vagus, or the nerve trunk may be in- 
volved by tumors or by poisons depressing the vagus nucleus. Irritation 
of the nerve causes a slowness of the heart's action. Bradycardia may 
follow irritation of the nucleus, as by compression by tumors, or it may be 
a pure neurosis. 

5. Paralysis of the oesophageal branches gives rise to difficulty in swallow- 
ing, which may simulate stricture. 

6. Paralysis of the gastric branches may cause a partial loss of power of the 
stomach to contract. 

The treatment of all such conditions depends upon the underlying 
cause. 

The spinal accessory (eleventh nerve) paralyses are seen in loss of function 
of the sternomastoid and trapezius muscles. This nerve is concerned in 
some cases with the pneumogastric in bulbar paralysis. 

The hypoglossal (twelfth) nerve is also concerned in bulbar paralysis. 
When the trouble is nuclear in origin, it may occur with locomotor ataxia 
or from acute softening from obstruction of blood vessels, and the symptoms 
are usually bilateral. The tongue atrophies. If the cause is supranuclear, 
paralysis of the tongue occurs on the side opposite to the lesion, and the 
tongue does not waste. It is usually associated with hemiplegia. If the 
cause is infranuclear, it may be from tumor, meningitis, pressure from 
bony caries, or a neuritis from rheumatism or lead poisoning. The tongue 
atrophies, and the reaction of degeneration is present. 

Symptoms. — In bilateral palsy the tongue cannot be protruded. In 
unilateral paralysis it deviates toward the paralyzed side when protruded. 
According to the extent of the paralysis is the interference with articulation 
and mastication. 

NEURITIS 

etiology. — Ordinarily, neuritis, an inflammation of nerve substance, 
takes place in a single nerve, but it may involve a plexus. Injuries, 
strains, pressure, compression, rheumatism, gout, infection, and occasion- 
ally the various toxines, as described under Multiple Neuritis, may affect a 
single nerve. 

Pathology. — There are two forms of inflammation, the parenchymatous 
and the interstitial, and the different microscopical structures show changes. 
46 



712 



THE NERVOUS SYSTEM 



Regeneration occurs by growth of new fibres outward from the healthy- 
portion into the old sheath. 

Symptoms. — The muscles supplied by the nerves involved show weak- 
ness or paralysis with atrophy and the reaction of degeneration. The skin 
of the region of the diseased nerve is numb or anaesthetic. Vasomotor and 
trophic changes, such as coldness, glossy skin, and oedema, are present. 
There are pain and tenderness, in the interstitial cases, at the point of in- 
flammation. 

Course. — When the continuity of the nerve is preserved, there is slow 
and spontaneous recovery. Otherwise there is no recovery. 

Treatment. — Unite the ends of the broken or cut nerve in injury 
cases. Rest the injured part, but exercise the muscles which are paralyzed 
by massage and electricity. Hot applications, sedative lotions, and pro- 
tection from the cold by cotton batting are useful. The pain may demand 
morphine. 

Multiple Neuritis 

Multiple neuritis is an inflammatory or degenerative disease of the per- 
ipheral nervous system. It affects symmetrical parts of the body and varies 
in different cases in extent and severity. 

The pathology is the same as in simple neuritis, and the inflammatory 
changes may be of both types or of either alone. 

jEtiology. — Toxic Cases. — Alcohol, wood alcohol, lead, arsenic, bisul- 
phide of carbon, copper, zinc, mercury, phosphorus, and coal gas are causes. 
Occasionally we see cases from excessive tea drinking. Ether, naphtha, 
ergot, and morphine are mentioned as causes. 

Cases Caused by Infectious Poisons. — Diphtheria, typhoid fever, scarlet 
fever, measles, malaria, leprosy, beri-beri, grippe, smallpox, syphilis, rheu- 
matism, tuberculosis, etc., are causes. 

Autotoxic Cases. — Gout, diabetes, etc., may give rise to the trouble. 

Cases with Cachectic Conditions. — Anaemia, tuberculosis, syphilis, septi- 
caemia, cancer, general malnutrition, or diabetes may be present. 

Symptoms. — The onset may be acute or subacute with or occasionally 
without fever. We observe the symptoms of a simple neuritis, but there 
are different types according to the different causes. 

1. Sensory symptoms are first to occur. There is sharp, severe pain 
located in the limbs, both along the nerves and in the muscles, which is 
increased by pressure or motion. 

Paresthesia occurs, such as burning, tingling, numbness, formication, 
and the sensation of a band about the legs or body. 

Ancesthesia, symmetrical, in the tips of the fingers and toes, extending 
up the limbs, is present. 

Ataxia is observed in the finer movements, also loss of the sense of 
position. 

2. Motor Symptoms. — Paralysis. — This appears in the extensor muscles, 
and we note dropped wrist or foot, with inability to walk or move about in 
bed. There may be paralysis of the cranial nerves. Contractures may 
develop. After the paralysis, atrophy develops rapidly, with loss or change 
of the electric contractility. There is no incontinence of urine. The deep 
reflexes are lost. 



MULTIPLE NEURITIS 



713 



3. Trophic Symptoms. — With the vasomotor paralysis we see glossy- 
skin, oedema, abnormal growth of the nails and hair, profuse sweating, and 
urticaria. There are no decubitus bedsores. 

Alcoholic neuritis is the most common form, and it occurs more fre- 
quently in women than in men. It resembles myelitis. The onset is 
usually sudden, with a chill and fever from 101° to 103°. There are usually 
delirium and delusions, with, later, an imperfect memory for recent events. 
The paralysis becomes complete with great pain and dropped wrists and 
feet. The anaesthesia, tremor, and tenderness are marked. In another 
form all the symptoms of locomotor ataxia, except those of the bladder 
and rectum, develop rapidly. In either form death may occur from heart 
failure or exhaustion. However, we usually see a rapid increase of symp- 
toms for three or four weeks, with a period of about two months during 
which the symptoms remain almost stationary, and then a slow recovery. 
The disease lasts from six to sixteen months. The combination of anaesthe- 
sia of the skin with extreme hypersesthesia and soreness of the muscles is 
highly suggestive of alcoholic neuritis. 

Cases Following or Complicating the Infections Diseases. — Diphtheritic 
neuritis is the most common. The paralysis begins in the uvula and may 
involve the muscles of the palate, eye, or heart, or be generally distributed 
in the extremities. There are usually no sensory symptoms. The paralysis 
is usually in the form of paraplegia. The duration is commonly about 
three months. 

Lead Paralysis. — There is usually a preceding colic, with anaemia, con- 
stipation, and the lead line on the gums. The onset of the palsy may be 
abrupt or gradual. It is without sensory disturbances, except rarely, when 
it may be accompanied with delusions. 

The prognosis of lead palsy is good, recovery gradually taking place in 
about four months. 

In arsenical cases there is usually a stomach disturbance at first. They 
resemble alcoholic cases. Paralysis with ataxia, tremor, atrophy, and great 
numbness, but with little pain, develops. The legs and arms are equally 
affected. "The steppage gait" is usually well marked. Recovery, accord- 
ing to severity of the neuritis, takes place in from two to six months. 

In coal gas neuritis the disturbance is chiefly sensory and not severe. 
Numbness remains for a long time in the fingers, hands, and feet. 

Epidemic neuritis, beri-beri, or kakke* is a disease which occurs endemi- 
cally in northern Brazil, China, Japan, India, the Straits Settlements, and 
the Malay Archipelago. It is probably due to infection, and occurs 
in several types — the acute pernicious, chronic cedematous, and chronic 
atrophic. At times it assumes epidemic proportions. Foreigners in the 
endemic localities are usually exempt. 

A gouty neuritis is sometimes seen in people who have other gouty mani- 
festations. They develop numbness and tingling, beginning in the feet or 
hands, and extending upward. The tingling is worse at night. There is 
weakness of the muscles, and the patient cannot walk far. It never goes 
on to paralysis or ataxia. 

Paralysis of the Musculospiral Nerve. — This produces "wrist drop " and 
inability to extend the last phalanx. The fingers can be only slightly 



714 



THE NERVOUS SYSTEM 



abducted; supination is lessened or lost; the triceps may be involved, 
weakening the power to extend the forearm. Atrophy may be present, 
also the degeneration reaction. There may be a swelling over the tendons 
of the wrist, some numbness and tingling, and some anaesthesia. 

In addition to the usual causes of neuritis, paralysis of the musculospiral 
nerve is frequently due to pressure on the nerve during sleep and anaes- 
thesia, also to crutches, fractures, wounds, and tumors. If it is due to 
pressure, and the pressure is removed, it lasts but a few weeks. 

Paralysis of the Circumflex Nerve. — In such cases it is impossible for 
the sufferer to elevate the arm or rotate it outward. Atrophy, anaesthesia, 
and sometimes pain are present. 

Differential Diagnosis of Neuritis. — We distinguish neuritis from anterior 
poliomyelitis by the pain and tenderness along the nerves, by the other 
sensory symptoms, and by the symmetrical distribution of the paralysis; 
from locomotor ataxia by the rapid onset, the paralysis occurring early, the 
preservation of control of the bladder, and the absence of the Argyll Robert- 
son pupil; from myelitis by the absence of bladder and rectum affections, 
the absence of bedsores, the absence of oversensitiveness of the spine to 
heat, and the peripheral distribution of the symptoms. 

Prognosis in Neuritis. — In the majority of cases it is good. In beri-beri 
there is a high mortality. The recovery is slow. When the heart becomes 
rapid and the respiration poor, showing an involvement of the pneumogastric 
nerve, the prognosis is bad. 

Treatment of Neuritis. — Enjoin rest in bed, order salicylic acid or the 
salicylates in the early stages, where there is fever, and make warm applica- 
tions to the affected limbs by means of packs or baths. After the acute 
stage has passed, we employ massage, vibratory stimulation, and warm 
baths at 98 c F. for half an hour, several times a day. Electricity in the 
form of the galvanic or faradic current may be passed through the nerves 
and applied to the muscles. Contractures should be avoided by passive 
movements and proper position of the limbs. Alcohol should not be given, 
except in the alcoholic cases, where it should be gradually reduced. Iodide 
of potassium is indicated in lead neuritis. The diet should be nourishing, 
but well regulated. Iron, quinine, and strychnine are indicated as general 
nerve tonics. For the pain, we may be obliged during the acute stage to 
give sedatives (phenacetin or morphine). In the chronic stage give arsenic 
and urge hydrotherapeutic measures. 

DISTURBANCES WITH LOSS OF CONSCIOUSNESS 
PREDOMINATING 

VERTIGO 

Vertigo, a pathological symptom, is characterized by giddiness, dizzi- 
ness, or the sensation of lack of equilibrium. When external objects seem 
to whirl around, it is said to be objective, and if the person himself seems to 
move, it is called szibjective. In rare cases it seems to be idiopathic. 

etiology. — Vertigo is observed from anaemia, hyperaemia, toxaemia, in- 
testinal toxaemia, alcoholism, the abuse of tobacco, arteriosclerosis, neuras- 



VERTIGO— DELIRIUM 



715 



thenia, epilepsy, and organic brain and spinal cord disease, such as tumor 
and hydrocephalus. We observe reflex vertigo due to eye strain, gastroin- 
testinal irritation, acoustic nerve irritation (Meniere's disease), or mechan- 
ical causes (swinging and electricity). 

Vertigo may be chronic or nearly so. The severe chronic form is called 
the status vertiginosits. Vertigo is increased by rising or sudden motions and 
diminished by lying down. 

Auditory vertigo, or Meniere's disease, is described under that head. 

Stomachic vertigo, accompanied by loss of consciousness, is a severe 
form. It occurs generally in persons whose stomachs are overloaded. 

Bilious and lithaemic vertigo are vague terms applied to conditions 
caused by indigestion. Dyspepsia, constipation, gout, and disordered 
stomach and bowel conditions create a toxic state of the blood which irritates 
the nervous centres. It is paroxysmal, being worse in the morning, is often 
accompanied by nausea, and is not very severe. 

Ocular vertigo denotes refractive errors and inequality of the action of 
the eye muscles. 

Neurotic Vertigo. — The form accompanying epilepsy is described under 
that head. Brain tumors and acute and chronic hydrocephalus give rise 
to vertigo. 

Neurasthenic vertigo is common. It is generally subjective and not 
severe, although it may cause much alarm. The attacks are short and 
may be accompanied by nausea or syncope. There is a form coming on in 
attacks which resemble seasickness, and they are analogous to other nervous 
crises. There is intense vertigo, coming on suddenly, with nausea and 
faintness, and lasting for some hours. Beyond overwork and excitement, 
there is no known cause. A form called "stumbling vertigo "is sometimes 
seen in neurotic individuals. There is a sudden "giving way " of the legs 
without consciousness of any vertigo. Patients with Graves's disease 
sometimes have this symptom. 

Mechanical Vertigo. — Swinging, whirling, and the movements of a ship, 
steam car, or elevator give rise to this form of vertigo in some people because 
of an irritation of the ocular and auditory nerves. 

Arteriosclerotic and Senile Vertigo. — Impaired nutrition of the brain, 
with consequent anaemia, may be the result of arterial changes. A weak and 
fatty heart may cause vertigo. 

Diagnosis. — Try to ascertain the cause by noting whether the vertigo 
is subjective or objective, paroxysmal or chronic, and whether it is accom- 
panied by ear symptoms, nausea, vomiting, or loss of consciousness. The 
auditory, gastric, toxic, and neurasthenic forms are the most common. 
Examine the arteries of elderly people and think of epilepsy in the young. 

Prognosis. — Epilepsy and organic disease give rise to the most serious 
forms. All the other forms can usually be relieved. 

Treatment. — The horizontal position, rest, and volatile stimulants are 
applicable to the attack. Then remove the cause if possible. 

DELIRIUM 

Delirium may be defined as a disturbance of the cerebral functions, 
manifested in the impaired action of the nerve centres, characterized by 



716 



THE NERVOUS SYSTEM 



§ 
o 

o 



Coma In Brain 
Injury, Cere- 
bral Concus- 
sion. 


Onset imme- 
diately after 
injury. 


Skull usually 
not fractured, 
no profound 
paralysis, pu- 
pils equally 
contracted 
and reach- 
ing to light, 
slow, shallow 
breathing, 
weak pulse, 
may be rapid 
and irregular, 
incontinence 
of urine. 


Rest, cold to 
head, light 
diet, gavage, 
s t imulation, 
enema, en- 
teroclysis. 

Surgical aid. 


Coma anrl Asphyx- 
ia: from Gas, 
Foul Air, or Car- 
bonic Oxide. 


Breathing il- 
1 u min atin g 
gas or bad air 
or coal gas. 


Mucous mem- 
branes livid 
and blue, 
noisy respira- 
tion, pulmo- 
nary oedema, 
small, rapid 
pulse, some- 
times convul- 
sions. 


Fresh air, arti- 
ficial respira- 
tion, hypo- 
dermic in- 
jection of 
whiskey and 
digitalis. 


Coma in Hepat- 
ic Cirrhosis or 
Acute Atrophy. 


History of al- 
cohol, syphi- 
lis, or infec- 
tion. 


Body jaun- 
diced, sallow, 
emaciated, 
small liver, 
large spleen, 
'sign of portal 
obstruction, 
epistasis, ha?- 
matemesis, or 
bloody stools, 
may have 
delirium or 
convulsions. 


Symptom- 
atic, about 
same as in 
diabetic co- 
ma. 


Belladonna Coma. 


Dry mouth and 
throat, coma 
preceded by de- 
lirium. 


Skin flushed and 
dry, slow, deep 
respiration, di- 
lated pupils, 
rapid pulse, re- 
tained urine. 


Emetics, stom- 
ach washing, 
catheter, en- 
teroclysis, hy- 
po dermoclysis, 
hypodermic 
stimulation. 


Opium or Morphine 
Coma. 


Onset gradual. 


Pale, cool skin, 
no paralysis, 
pupil contract- 
ed, slow, irregu- 
lar respiration, 
difficult to 
rouse patient. 


Wash stomach, 
enema, catheter, 
strong coffee, 
artificial respi- 
ration, flagel- 
lation, atro- 
pin sulph., gr. 
tm, hypodermi- 
cally, strong 
faradic current. 


Diabetic Coma. 


History of dia- 
betes, slow on- 
set. 


Pale skin, no 
paralysis, rapid, 
shallow breath- 
ing, normal 
t e m per ature, 
rapid, weak 
heart, sweet or 
acetone smell to 
breath, sugar in 
urine, no con- 
vulsions as a 
rule, profound 
stupor. 


Enema, cathe- 
ter, keep lips 
and nose moist, 
enteroclysis at 
110° F., sustain 
heart, saline 
hypodermocly- 
sis, morphine, 
in case of con- 
vulsive seiz- 
ures. 


Alcoholic Coma. 


Follows alcohol- 
ic delirium. 


Congested face 
and eyes, hot 
skin, no paraly- 
sis or tongue de- 
viation, usually 
no fever, rapid 
respiration , 
large pupil, 
strong pulse, 
alcohol breath, 
vomiting, sel- 
dom convul- 
sions, urine re- 
tained, no vis- 
ible injury, can 
be aroused. 


Enema, cathe- 
ter, cold to 
head, heat to 
body, keep lips 
moist, also nose, 
sustain heart, 
enteroclysis at 
110° F. 


Apoplectic Coma. 


Follows in the 
wake of sudden 
hemiplegia. 


Pale skin, no 
sign of injury 
or hoemorrhage, 
paralysis evi- 
dent, slow ster- 
torous breath- 
ing, irregular, 
weak pulse, 
sometimes fe- 
ver, involun- 
tary flow of 
urine, profound 
stupor, devia- 
tion of tongue. 


Enema, vene- 
section, ice to 
the head, hot 
water bottle to 
the feet, feed 
with care, gav- 
age, absolute 
rest, keep lips 
and nose moist 
rectal feeding. 


1 
o 

S 

a 


Acute or chronic 
nephritis, d e - 
lirium, convul- 
sions, profound 
coma. 


Pale, cyanotic, 
oedematous 
face or general 
dropsy, stertor- 
ous breathing, 
usually fever 
temper ature, 
full pulse, albu- 
min and casts 
in urine, re- 
peated convul- 
sions, no sign 
of injury or 
paralysis. 


Enema, vene- 
section, hot 
pack, draw 
urine with 
catheter, enter- 
oclysis at 115° 
F., decapsula- 
tion of kidneys. 




History and 
onset. 


Examination. 


Treatment. 

1 



COMA 



717 



s t 

a " 

a s 

b 


Occurs in 
males, but 
more in fe- 
males, also in 
children, on- 
set sudden. 


E x a m i nation 
reveals noth- 
ing particular- 
ly abnormal; 
coma may al- 
ternate with 
hysterical cry- 
ing. 


Look wise 
and say little; 
feigned coma 
is very mis- 
leading. 


Syncope. Cerebral 


Sudden onset. 


Pale, clammy 
skin, some- 
times nausea, 
slow, weak 
heart, sighing 
respiration, 
sometimes 
con vulsions, 
coma of short 
duration. 


Loosen the 
clothes, lower 
the head, cold 
douche, am- 
monia to 
nose, hypo- 
dermic of 
II 1 R It 6 y or 
strychnine. 


3 g 
= S 

If 

O 


Death or co- 
ma. 


Superficial or 
deep burns, 
disturbance 
of vision 
after return 
of conscious- 
ness, or par- 
alysis in 
some cases. 


Artificial res- 
piration, ex- 
ternal heat, 
stimulation. 


£ 
E 

u 


Exposure to in- 
tense cold com- 
bined with fa- 
tigue, hunger, 
and alcoholism. 


Comatose con- 
dition and 
varying degrees 
of frostbite, 
from congestion 
to blistering 
and gangrene. 


Preventive by 
protection and 
maintenance of 
circulation, ap- 
plication of 
warmth, stimu- 
lation ; chil- 
blain, when re- 
cent, may be 
rubbed down 
with snow; 
when of long 
standing, mas- 
sage is indi- 
cated; gangrene 
is treated anti- 
septically. 


Coma in Sun- 
stroke. 


Exposure to sun 
combined with 
fatigue and al- 
coholism, onset 
abrupt or pre- 
ceded by pain 
in head, vertigo, 
nausea. 


Pulse rapid and 
bounding, ster- 
torous breath- 
ing, skin hot 
and dry, eyes 
suffused, tem- 
perature very 
high, delirium, 
convulsions, 
rigidity after 
recovery, pain 
in head may 
continue and 
mental weak- 
ness, chronic 
meningitis, and 
insanity result. 


Cold applica- 
tions, tubbing 
at 60°, or cold 
pack, cold ene- 
mata, venesec- 
tion, stimula- 
tion, ice to head. 


Coma in Insulation, 
Heatstroke. 


Exposure com- 
bined with 
physical exer- 
tion and alco- 
holism, onset 
sudden or grad- 
ual. 


Skin cool and 
clammy, face 
pale, pulse rapid 
and feeble, in- 
voluntary dis- 
charges, coma 
yields to treat- 
ment. 


Cool douche and 
friction, warm 
baths, stimula- 
tion, fresh air to 
breathe, cam- 
phor, whiskey, 
digitalis. 


Epilepsy, Postepi- 
leptic Coma. 


History of epi- 
leptic seizures. 


Pale or cya- 
no tic skin , 
frothing at 
mouth, tongue 
bitten, seminal 
discharge, pu- 
pils react to 
light, pulse, 
temperature, 
and respiration 
not character- 
istic. 


Symptomatic ; 
wait for con- 
sciousness. 


Coma in Menin- 
gitis, 


History of men- 
ingitis, coma 
after days and 
weeks of illness. 


Con j un c ti vse 
congested, 
t&ehe me"ningi- 
tique, Kernig's 
sign, sphincter 
paralysis, pu- 
pils dilated with 
intracranial ef- 
fusion. 


S ymptomatic; 
catheter, en- 
teroclysis, feed- 
ing by gavage, 
rectal feeding. 


io 

E ■§ g 
| J J 


History of inju- 
ry, may recov- 
er and relapse 
some hours 
afterward. 


Skull often frac- 
tured, blood 
and serous dis- 
charge from 
nose or ears, lo- 
calized and gen- 
eral paralysis, 
pupils first un- 
equal, then di- 
lated and no re- 
action to light, 
respiration may 
be of Cheyne- 
Stokes type, 
pulse first 
slow, afterward 
rapid and ir- 
regular, reten- 
tion of urine, in- 
creasing stupor. 




Rest, cold to 
head, light diet, 
gavage, enema, 
enteroclysis, op- 
eration, rectal 
feeding. 




History and 
onset. 


Examination. 


Treatment. 



718 



THE NERVOUS SYSTEM 



hallucinations, incoherence of speech, a staggering gait, etc. There is 
dissolution of the "ego " for the time being. It may be due to high fever 
or to the poison causing the fever, as in typhoid or scarlet fever. In such 
cases it has no important significance beyond denoting a severe injection. It 
may appear before and after the crisis, and may be a sign of weakness and 
collapse (inanition of the brain). 

The delirium from toxaemia may be mistaken for meningitis. Delirium 
from alcoholic poisoning may be acute or it may be due to chronic alcohol- 
ism, as in delirium tremens. 

Various forms of junctional and organic nervous and mental disease may 
be accompanied by delirium. 

Treatment. — When active delirium is due to toxaemia, with a high tem- 
perature, hydrotherapeutic measures are indicated (see General Thera- 
peutics). When there is the low, muttering delirium of excessive weakness 
or collapse, active stimulation is indicated. 

COMA 

Coma may be defined as abnormally deep and prolonged sleep, with the 
cerebral functions in abeyance. It may be caused by a number of different 
factors, and it is many times impossible to determine the cause in an un- 
conscious person, seen for the first time in coma and without a history. 

The table (pages 716-717) will prove an aid in distinguishing the dif- 
ferent causes leading to coma, and in establishing proper treatment. 

ECLAMPSIA; CONVULSIONS 

Convulsions are abnormal and exaggerated muscular contractions occur- 
ring in rapid succession. They may be clonic, a rapid and alternate con- 
traction and relaxation of the muscles in an exaggerated or irregular way, 
or tonic, a steady and continuous contraction. A cramp is a painful tonic 
contraction of a muscle. Convulsions may be coordinate, when the limbs 
and body are moved about in a more or less purposeful way. The patient 
throws himself about on the bed, jumps, strikes, kicks, tears the clothes, 
etc. There is usually loss of consciousness with convulsions. 

Convulsions occur in epilepsy, at the onset of acute infectious disease, 
especially in children; in hysteria, extension of inflammation of the middle 
ear, in concussion of the brain, in cerebral anaemia, in cerebral haemorrhage, 
in cerebral syphilis, in general paralysis, in infantile hemiplegia, in menin- 
gitis, in sunstroke, after aspiration of pleural fluid (rare), in acute yellow 
atrophy of the liver, in chronic Bright's disease, in the form of puerperal 
eclampsia, in uraemia, in rickets, in indigestion, in tetany, in hepatic colic, 
in hydrophobia, in typhoid fever, in tetanus, in alcoholism, in poisoning, 
and from many other causes. 

The symptomatic management of convulsive seizures is discussed in 
the section on Paediatrics. 

PUERPERAL ECLAMPSIA 

This is an acute derangement which may occur in the pregnant, par- 
turient, or puerperal woman, characterized by clonic convulsions with loss 



PUERPERAL ECLAMPSIA 



719 



of consciousness and coma. Although the kidneys, liver, and brain, to- 
gether or separately, particularly the kidneys, show pathological changes 
of varying and inconstant severity at the autopsy, they are not severe 
enough to indicate them to be the characteristic lesions of the disease. 
It is probable that convulsive seizures are caused by some unknown toxic 
material circulating in the blood (convulsive bodies). 

Symptoms. — From 70 to 80 per cent of the cases occur in primiparae. 
As a rule, it does not occur until after the second half of pregnancy, and it 
becomes more frequent as pregnancy advances. Twin pregnancies and 
hydramnios seem to predispose to the disease. 

A convulsion may occur without warning in an apparently healthy 
pregnant woman, but usually there are premonitory signs, such as albumi- 
nuria, oedema, headache, epigastric pain (an important sign), and possibly 
disturbance of vision. It may come at any time, even during sleep. If 
the patient is awake, the first sign is a fixed expression of the eyes, which 
soon begin to roll from side to side. The pupils are usually dilated, but 
they may be contracted. The convulsive movements appear first around 
the mouth, which twitches and is drawn to one side. The whole face be- 
comes distorted, and the convulsions rapidly extend to the arms, body, 
and legs. They are usually clonic in character, but sometimes the patient 
may become rigid in a tonic spasm. The breathing becomes stertorous, 
the face grows congested and flushed, and the patient foams at the mouth 
and often bites her tongue. It may last from a few seconds to two minutes, 
and there is absolute unconsciousness during this time. A condition of 
coma follows, lasting for a variable time. It may last from one convulsion 
to another, and the patient may die without recovery of consciousness. If 
the convulsions are infrequent, consciousness is usually regained after each 
convulsion. 

If the attack occurs during the latter part of labor or during the puer- 
perium, there is often but a single convulsion, with recovery. More often 
one convulsion is followed by another. In mild cases there are one or two, 
and in fatal cases there may be as many as a hundred. In rare instances 
they may follow one another so rapidly that the patient seems to remain 
in a continuous convulsion. 

Usually the arterial pressure is markedly increased, with a full, bounding 
pulse. In severe cases it is weaker, thready, and more rapid. The tem- 
perature is very high in many cases, 104° or 105° not being unusual, and 
it may be 107° or 108° in fatal cases. Sometimes it remains normal. 
Most clinicians agree that the largest number of cases occur during labor, 
the next before labor, and the last after labor. 

If the attack occurs before labor, the pains may begin and the child be 
born spontaneously, or the patient may recover and at term be delivered 
of a living child, or she may recover and at some future time be delivered of 
a dead foetus, or she may die undelivered. In exceptional cases she may 
recover from the attack and, after being perfectly well for a longer or shorter 
period, have a recurrence of the seizure. If the attack occurs first during 
labor, the pains increase in frequency and severity, and the child is born 
sooner than usual. The convulsions usually cease after delivery. The 
patient may die undelivered unless some operative procedure for delivery 



720 



THE NERVOUS SYSTEM 



is adopted. The postpartum attacks usually come on soon after delivery, 
and recovery often follows one convulsion. In some postpartum cases, 
however, there may be many convulsions, and occasionally death may 
result. In a small number of cases the patient becomes jaundiced, and 
the prognosis is grave. 

The urine during an attack is markedly diminished in amount and 
contains many casts and often blood. Occasionally there is complete sup- 
pression. Nearly always albumin is present in large amounts, and the urea 
is greatly diminished. In favorable cases, after the convulsions the urine 
and urea are increased and the albumin diminished. Usually the urine 
improves rapidly and in a few weeks may appear normal. There may, 
however, be albumin and casts in the urine for months afterward. Death 
usually results from oedema of the lungs, apoplexy, aspiration pneumonia, 
or a puerperal infection. 

Diagnosis. — If the patient has been under observation during her preg- 
nancy, the diagnosis is easy. If she is seen for the first time in convulsions 
or coma, we have to distinguish the cause from uraemia, epilepsy, and 
hysteria. 

Prognosis. — The disease is always grave, being considered one of the 
most serious of obstetrical complications. The maternal mortality is from 
20 to 25 per cent and the fcetal is from 33 to 50 per cent. Each convul- 
sion makes the outlook more serious. Death may occur after the first 
convulsion, and recovery after as many as thirty. If the pulse remains 
good, firm, and full between the attacks, the outlook is usually good; if 
it becomes weak, rapid, and thready, it is usually a bad sign, especially if 
accompanied by high fever. The most serious complications are apoplexy, 
paralysis, and pulmonary cedema, which usually result fatally. 

Treatment. — Prophylactic. — From the beginning of pregnancy, a 
woman should be instructed in regard to the necessity of keeping all the 
emunctories in perfect working order. The kidneys should secrete freely 
and much fluid be taken. The bowels should move freely every day. 
The skin should be kept in perfect order by means of baths and exercise. 
The lungs should have plenty of fresh air. Exercise is imperative, and 
walking is one of the best exercises. 

The urine should be examined every month until the last month, when 
it should be examined every week. The patient should aotify her physician 
of headache, disturbance of vision, cedema, or epigastric pain. If we find 
albumin in the urine, we should get a twenty-four hour specimen and ascer- 
tain the total amount of albumin and urea. If the urea is normal (16 to 
30 grammes per diem), and there is a slight amount of albumin, the signifi- 
cance is not important. If there is considerable albumin and the urea is 
diminished, the patient is in a serious condition. The patient should be 
put to bed and placed on a fluid diet. After a few days she can have 
soft diet. She should drink a good deal of fluid, such as water, lithia 
water, peppermint tea, and lemonade. The result of this treatment is 
usually good. If not, give a saline purge daily and a hot'- pack or sweat 
bath daily. If there is improvement, the prognosis is good. If the 
albumin increases and the urea diminishes in spite of treatment, the 
prognosis is bad, and labor must be induced. 



EPILEPSY 



721 



Curative Treatment. — When the convulsions begin, chloroform should 
be given, and then morphine, gr. \, to be repeated twice if necessary. 
Diuresis must be provoked by means of hot packs. A strong cathartic must 
be given, such as one drop of croton oil in 3j of olive oil. If the patient is 
unconscious, it can be dropped on the back of the tongue. Place something 
between the teeth, such as a folded handkerchief, to prevent the biting of 
the tongue. No food or medicine should be given by the mouth during 
unconsciousness. Terminate labor as soon as is possible with safety. If 
the foetal head is low down after dilatation is complete, apply the forceps. 
If it is above the brim, perform version. If the attack comes before labor 
has begun, use a steel dilator to make space enough for the Champetier de 
Ribes balloons. 

After delivery, do not try to check haemorrhage until a considerable 
quantity of blood is lost, as this loss is helpful. Promote diuresis and 
catharsis. Give salines per rectum and subcutaneously, according to need. 
A continuous irrigation of the rectum with saline solution at 115° F. is 
one method of treatment. If the haemorrhage is slight, venesection may 
be necessary. In urgent cases decapsulation of the kidneys, according to the 
method of Edebohls, is indicated. 

EPILEPSY 

Idiopathic epilepsy is an organic disease of the cerebral cortex character- 
ized by attacks of unconsciousness with general convulsions. 

Jacksonian epilepsy, partial epilepsy ; cortical epilepsy ; symptomatic 
epilepsy is usually symptomatic in form, and is characterized by periodical 
convulsions affecting only certain groups of muscles and often unattended 
by unconsciousness. It is due to disturbance of the projectional motor 
centre. 

Hysteroepilepsy is a form of hysteria. 

Idiopathic epilepsy is seen in three forms, grand mal, petit mal, and 
psychical epilepsy. 

Petit mal is the form where there is an attack of unconsciousness, but 
no convulsion. 

Grand mal is the form where there is unconsciousness with convulsions. 

Psychical epilepsy is a rarer form characterized by acute mental disorders. 

etiology. — Heredity is the most important of remote causes, as a 
neurotic family history can be obtained in about one quarter of all cases. 
It is rare to have a history of epilepsy in the father or mother, but we often 
find one or both suffering from a nervous disease or alcoholism. Epilepsy 
or insanity is found in the family history of about one third of the cases. 
Intermarriage of neurotic persons contributes powerfully toward the 
tendency to convulsions in children. We find an exciting cause in about 
one third of the cases. Blows on the head, dissipation, fright, and continued 
reflex irritation act as causes. Acute infectious diseases, powerful emotions 
during pregnancy, injuries during labor, and syphilis have some influence. 
Rickets, sunstroke, masturbation, eye strain, ear irritation, dyspeptic 
states, and lesions involving the peripheral nerves are among the more 
important of the exciting causes. There is a slight preponderance of cases 
among males. 



722 



THE NERVOUS SYSTEM 



We see the greatest number of cases between the ages of ten and fifteen. 
It occurs very seldom after twenty. If it develops after thirty-five, it is not 
idiopathic, but is usually due to syphilis, alcoholism, plumbism, or injury. 

Symptoms. — Grand Mal. — A patient may feel premonitory symptoms 
for some days, such as general malaise, irritability, or giddiness. In about 
half the cases the attack begins with a peculiar sensation called the aura, 
which gives a warning to the patient that an attack is impending. There 
are different forms of aurae, the sensory being the most common. A sensa- 
tion as of a mist is felt in some part of the body, mounting toward the head. 
There are ocular aurce, such as flashes of light or color, strange forms, 
double vision, or blindness; auditory aurce, such as strange voices or sounds; 
olfactory aurce, such as a sensation of a disagreeable odor; and psychical 
aurm, such as alarm, terror, or a strange dreamy sensation. Forced move- 
ments may precede an attack, such as moving forward rapidly, " procursive 
epilepsy," or rapidly turning around as on a pivot. Just preceding the 
attack, which is abrupt, the patient usually utters a wild cry, scream, or 
groan and falls to the ground unconscious. We may divide the convulsions 
into three stages: 

1. Tonic Spasm. — The face is pale; the head, eyes, and mouth are drawn 
back and rotated to one side. The whole body is in a state of rigidity. 
The hands are clenched, the arms and forearms flexed, the legs extended, 
and the feet extended and inverted. The distortion of the body is not 
always the same. There is a respiratory spasm also, which makes the face 
dusky or livid. This stage lasts from a few seconds to one or two minutes, 
and merges into the second. 

2. Clonic Stage. — There are tremulous vibrations, which increase until 
the limbs are jerked and violently tossed about. The face muscles in the 
clonic spasm cause frightful contortions. The eyes roll; the eyelids are 
opened and closed; the pupils are immovably dilated, but oscillate after 
the attack. Foamy saliva is forced from the mouth, and the tongue is 
likely to be bitten. The respirations are noisy and stertorous. Urine and 
fseces may be passed involuntarily, especially in the night attacks. The 
temperature is usually normal, but there may be a slight rise. This stage 
rarely lasts more than one or two minutes, and the patient passes into the 
third stage. 

3. Stage of Coma. — A deep sleep, with or without noisy breathing. After 
a few minutes or hours, the patient wakes with a headache or mental con- 
fusion and muscular soreness. 

Status Epilepticus. — The attacks may follow one another in rapid suc- 
cession, without the patient's regaining consciousness. The pulse, respira- 
tion, and temperature rise, and the condition becomes serious. Death may 
ensue from exhaustion. 

Postepileptic Symptoms. — After emerging from the coma, the patient 
may appear as in a trance and move about performing senseless and pur- 
poseless actions, although he seems perfectly conscious. This condition of 
epileptic automatism may pass into epileptic mania, in which condition 
the patient is dangerous to those about him. A slight and transient hemi- 
plegia or aphasia may be noticed after an attack. Mental impairment and 
ultimate dementia may be the result of attacks of epilepsy. 



EPILEPSY 



723 



Nocturnal Epilepsy. — People may have attacks of epilepsy in their 
sleep, and at no other time, so that the condition may exist for years with- 
out the patient or his friends knowing it. 

Petit Mal. — There is a sudden loss of consciousness, so that the patient 
stops what he is doing, his face becomes pale and fixed, and his pupils 
dilate. In a few seconds he regains consciousness and continues what he 
was doing as if nothing had happened. Aurae seldom occur in this form, 
but if they do, they usually consist in forced movements. 

Psychical Epilepsy. — The patient may perform some peculiar auto- 
matic action, such as undressing himself, tearing anything within reach, 
rubbing his face and beard, or spitting about in a careless way. Sudden 
outbursts of maniacal excitement may take place, and during these 
("masked epilepsy"); crimes and particularly assaults maybe committed. 
There are many different manifestations of petit mal. 

An attack may terminate in facial twitchings or sudden jerkings in the 
limbs, sudden tremor, or sudden visual sensations. In the majority of cases 
grand mal ultimately develops. The two forms may alternate. 

Jacksonian Epilepsy. — This form is caused by some irritation of the 
motor centres, especially of the cortex of the brain. Consciousness is not lost 
in these attacks, or only very late in the attack. The spasm begins in a 
group of muscles, and extends until the whole limb or face is involved. 
There may be premonitory numbness and tingling. The extent of the brain 
lesion may increase, making the convulsions involve more muscles. The 
convulsions may become general. 

Diagnosis. — Petit mal is simulated by syncope, Meniere's disease, 
cardiac lesions, and indigestion. In these there is no actual loss of con- 
sciousness, which we usually see in petit mal. Grand mal is simulated by 
the convulsions from uraemia, simple convulsions in children, convulsions 
from organic brain diseases, malingering, and hysteria. In uraemia there 
is scanty, albuminous urine with high arterial tension. Convulsions in 
children can usually be traced to some readily recognized cause. In or- 
ganic brain disease (tumors, paresis) the history and other symptoms usu- 
ally serve to distinguish them. Malingerers do not bite their tongues and 
do not foam at the mouth, and the attack can be stopped by strong pres- 
sure over the supraorbital notches. Gowers has formulated the following 
table to distinguish epilepsy from hysteria, which may closely resemble it. 



Epilepsy 



Hysteria 



Apparent Cause. 
Warning. 



None. 



Emotion. 



lateral or epigastric aurae. 
Always sudden. 



Any, but especially uni- 



Palpitation, malaise, chok- 
ing sensation. 



Onset. 

Scream. 

Convulsion. 



Often gradual. 



At onset. 



During course. 



Rigidity followed by "jerk- 



ing," rarely rigidity alone 



Rigidity or "struggling," 
throwing about of limbs 
or head, arching of back. 



Biting. 



Tongue. 



Lips, hands, or other people 
or things. 



724 



THE NERVOUS SYSTEM 



Epilepsy 



Hysteria 



Micturition. 
Defcecation. 
Talking. 
Duration. 



Frequent. 

Occasional. 

Never. 

A few minutes. 



Never. 
Never. 
Frequent. 

More than ten minutes 



Restraint 

necessary. 
Termination. 



To prevent accident. 



often much longer. 
To control violence. 



Spontaneous. 



Spontaneous or induced (by 
water, etc.). 



Prognosis. — Except in Jacksonian epilepsy and in certain forms of 
reflex epilepsy, the prognosis is not good, although treatment will give con- 
siderable relief. It does not tend to markedly shorten life. In a large 
number of cases the mental faculties are considerably impaired, but many 
epileptics lead an active, useful life. Where the convulsions develop in 
adults, particularly when they are caused by syphilis, and in children in 
acute fevers, the prognosis is better. 

Treatment. — In Jacksonian epilepsy we may be able to remove the 
cause, as by antisyphilitic treatment or by surgical means. If rickets, 
eye strain, ear irritation, or digestive disturbance exists, treat it. If there 
is an irritation from a long and tight prepuce, perform circumcision. How- 
ever, even with the removal of the cause, where the condition has existed 
for some time, the results are imperfect, for there seems to be a habit of 
nerve discharge established. 

Where the aura is slow, we may be able to check the spasm by inhala- 
tions of nitrite of amyl. If there is an ascending sensory aura, we may 
abort the spasm by tightly encircling the part with the hands or a tight 
bandage. Usually, however, the aurae are too short to allow of any prevent- 
ive measures. 

During the attack we should have the patient on his back, with the 
clothes loosened and something placed between the teeth, such as a hand- 
kerchief, to prevent the tongue from being bitten. If the convulsions are 
severe, we may administer a little chloroform by inhalation or morphine 
subcutaneously. 

General Treatment. — In the case of children the parents should under- 
stand that the disease is incurable, but that much can be done by proper 
management. The children need firm, but kind treatment. If caprices 
and whims are indulged, moral control, which is so necessary in these cases, 
is weakened. As most patients are not incapacitated for occupation, they 
should be educated and have some definite pursuit. Should the mental 
impairment become marked, and the patient become extremely irritable 
or violent, it is better to place him in an institution under competent super- 
vision. An outdoor life with exercise, hygiene, and proper diet has a very 
great influence for good. Marriage should be interdicted. 

It is better to order a diet mainly vegetable, although meat may be per- 
mitted once a day. Regularity in meals is important, and overloading of 
the stomach should be prevented. 



EPILEPSY 



725 



Medicinal Treatment. — Bromides seem to have a special influence. 
The mixed bromides and bromomangan give the best results. The drug must 
be well diluted in water or milk, and should be administered up to the pro- 
duction of mild bromism, shown by drowsiness, mental depression, a foul 
breath, and muscular weakness, and then the dose reduced until the patient 
is kept just within its physiological action, known by the loss of the palate 
reflex. By diluting the medicine with alkaline waters, and also giving 
arsenic, the tendency to acne is diminished. From 5ss. to 3ij of the bro- 
mides a day is usually a sufficient dose for an adult, and we should strive to 
give a full dose some time, from four to six hours, before an attack is likely 
to occur. The bromide treatment should be continued for two or three 
years after the cessation of the attacks. Some patients do not stand the 
bromides well, and we must depend on other drugs, but principally upon 
outdoor exercise, hygiene, and proper diet. 

Other drugs have been recommended. Antipyrine with the bromide 
is of value. A combination of bromide of ammonium, gr. xx to xxx, 
antipyrine, gr. vij, and Fowler's solution, mij to iij, twice daily, is recom- 
mended. Sulphonal may be administered with the bromide, also chloral 
and cannabis indica. 

SLEEPING SICKNESS; NEGRO LETHARGY; TRYPANOSOMIASIS 

This is an endemic disease of western Equatorial Africa characterized 
by drowsiness, mental and physical lethargy, and muscular debility. It 
generally proves fatal after a period of months or years. 

^Etiology. — Quite recent investigations by an English commission seem 
to indicate that the disease is caused by a variety of trypanosoma in the 
cerebrospinal fluid and blood. It is possible that there is another con- 
comitant factor, particularly in the later stages of the disease. From the 
distribution of the tsetze fly, " the inference that that insect carries the 
trypanosoma is almost unavoidable." 

Symptoms. — Prodromal. — Increasing drowsiness and muscular feeble- 
ness. This period may last for from some months to one or two years. 

Declared. — Pronounced somnolence, intense muscular prostration, and 
at times tremor. In this stage the patient is unable to walk and eats only 
when food is brought to him. 

Final. — Spasmodic contractions of muscular groups, paralysis, bedsores, 
wasting, often convulsions and coma. Mania may supervene at any stage. 
There is a great difference in the variety and intensity of the symptoms. 

Treatment. — In the light of the recent investigations, it would seem 
possible to prevent the disease. If the natives could be protected from the 
tsetze fly, probably no cases would occur. Until now, the treatment has 
been symptomatic. Arsenic has seemed to be of benefit in some cases. 

DERANGEMENTS WITH PSYCHICAL ALTERATIONS 
PREDOMINATING 

GENERAL REMARKS 
Functional nervous derangements make up the bulk of medical practice, 
and they can usually be benefited and cured. In the activity of the age, 



726 



THE NERVOUS SYSTEM 



the ambition for fame, money, and pleasure has become so contagious that 
many people are led to extremes of every sort. Rules of hygiene are utterly 
disregarded, and overworked nerves will manifest themselves sooner or later. 

The natural credulity of man, the mental condition resulting from over- 
fatigue and unaccomplished or defeated ambitions, the peculiar innate 
desire of man to attain the unattainable, make him a prey to those people 
who, clever enough to recognize these facts, establish cults and societies, 
disguised under Christian titles, as pseudooccult mysticism. Neurotic 
people are led to disregard their nervous or psychical ailment in their en- 
thusiasm over the "new thought," and receive a suggestion that they are 
happy and are not ill, which benefits or cures them. 

The physician should recognize such cases, and should treat them, as 
they need to be treated, by mental suggestion. We may call it " hypnotism," 
" mental cure," or by any truthful name, and it is much better for the intelli- 
gent, educated physician to keep these patients than to let them fall into 
the hands of the clever but unscientific, uneducated and dishonest leaders 
of cults. 

NEURASTHENIA 

Neurasthenia is a functional disorder of the entire nervous system de- 
pendent upon malnutrition and characterized by nervous weakness and 
irritability. Nervous prostration, nerve tire, nervous exhaustion are 
synonyms. Hypochondriacs is a term applied to those neurasthenics who 
are uneasy in regard to their health and depressed in spirits. 

jEtiology. — Nature demands a balance between the storing and expendi- 
ture of energy. If this demand is disregarded, exhaustion results. Some 
one has said that the cells of the body demand twice as much rest as work. 

Forms. — We speak of primary and secondary forms. 

1. Primary neurasthenia, or that caused by excessive expenditure of 
nervous energy. Underlying this there may be an hereditarily weak nervous 
system; feeble health during childhood, which favors a poor nervous system; 
vicious early education and training; exhaustion from the effort to excel 
or even to exist; anxiety, worry, mental depression, and fear; overwork, 
mental or physical; sexual overindulgence; and overstudy. Doubtless in 
young children who are pushed beyond their capacity by overambitious 
parents or tutors neurasthenia may exist with favorable hygienic surround- 
ings, but the great majority of cases are due to unsystematic, unscientific, 
and poor methods in the acquisition of knowledge. The mind of a student 
who is perfectly well physically, of one who exercises out of doors, who 
sleeps well and sufficiently, who has plenty of suitable food, and who has 
sufficient diversion, is very unlikely to be overworked, but rather to remain 
in a healthy condition. A student should have a healthy body, should learn 
to be methodical and regular in his habits, learn to concentrate his mind 
and study with good methods, and allow sufficient time for exercise, sleep, 
and diversion. 

2. Secondary neurasthenia is due to a deficient supply of nervous 
energy. Leading to this are diseases of all kinds of an organic nature, which 
weaken the nervous system; autoinfection as a result of indigestion; con- 
stitutional diathesis, including gout and rheumatism; infectious diseases, 



NEURASTHENIA 



727 



such as typhoid fever, grippe, and malarial disease; and poisons, including 
alcohol, tobacco, and drugs, such as morphine, cocaine, and chloral. 

Symptoms. — Cerebral — There is headache, which may be occipital or 
frontal, and dull in character, with vertigo, insomnia, sensitiveness of the 
scalp, and peculiar sensations, such as fulness, pulsation, and the feeling as 
if a band were about the head. Mental capacity to work is impaired; the 
memory is poor; concentration is difficult; the patient is irritable; there 
are prominent peculiarities of disposition; the patient has morbid fears of 
people and places, is anxious and apprehensive; and the respiration is im- 
perfect and the pulse rapid. 

Spinal. — There is actual pain, especially in the back of the neck and in 
the sacrum ; there is a sensitiveness about the ribs and along the intercostal 
nerves; different parts of the body may feel supersensitive or irritated; the 
legs do not seem strong enough to hold one up. Sexual irritations are 
common; there may be erections, emissions, impaired power, or irritability 
of the bladder or urethra, with frequent urination. 

Vasomotor Symptoms. — There are hot and cold sensations, cold feet 
and hands, sweating, transitory blueness or swelling, the tache cerebrale 
of Trousseau, tachycardia, and palpitation of the heart. 

Gastrointestinal Symptoms. — Indigestion and dyspepsia occur, par- 
ticularly the form known as hyperacidity, and there may be constipation, 
flatulence, or pseudomembranous colitis. 

Sensory and Motor Symptoms. — There are indefinite pains and par- 
aesthesise, joint affections, apparent paralysis, but with no change in the 
electrical reactions, and imperfect vision, asthenopia. The visual field may 
be contracted. Sometimes other senses may be affected, as with tinnitus 
aurium. 

It is seldom that we see all these symptoms in one patient. Many times 
some one or some group is very pronounced, and the others are not present. 
They change from day to day. 

Diagnosis. — If we can find a cause for nervous exhaustion other than 
organic disease, we may, by "sizing up " the patient, by noting the vari- 
ability of the symptoms and the disproportion between the complaint and 
the actual trouble, pronounce the trouble neurasthenia. The physician 
should be very careful to exclude organic disease. 

Treatment. — Preventive. — Try to teach patients how to live. Kant's 
rule, eight hours for work, eight for diversion, and eight for sleep, is a very 
good one to follow if you have money. See that the children are being 
educated and trained properly. 

The treatment of the disease is very unsatisfactory, for it takes a long 
time to reestablish the nerve energy. Rest, proper food, exercise, hydro- 
therapy (cold douches) , and diversion should be resorted to. The treatment 
should be very systematic and very varied, to keep the patient interested, 
contented, and yet free from fatigue. 

Drugs may be used when necessary to meet the symptoms. Tonics, 
sedatives, and electricity are indicated. The glycerophosphates seem 
the best modern drugs for nervous fatigue. The use of cacodylate of 
sodium subcutaneously has given good results. Vibratory massage is 
excellent. Static electricity and the high frequency current are popular. 
47 



728 



THE NERVOUS SYSTEM 



HYSTERIA; HYSTEROEPILEPSY 

"A functional disturbance of the nervous system, characterized by 
mental and moral perversion, lack of self-control, and disorders of any or 
all of the bodily functions." 

iEtiology. — It is a product of modern civilization, and is more prevalent 
in women than in men. It may appear at any age, but is most common 
between the ages of fifteen and twenty-five. Hereditary influence is consider- 
able, as in many cases there is a family history of nervous troubles. Im- 
proper early training is largely at the root of it, creating a lack of moral 
responsibility and self-control. Directly, the emotions — fear, anxiety, 
jealousy — unhappy love affairs, domestic worries, sexual excess, masturba- 
tion, physical conditions, such as indigestion, bad habits, injuries, and 
accidents, especially those attended with fear, and anaemia causing mal- 
nutrition of the nervous system and ovarian or uterine disease, may cause 
hysterical conditions. 

Pathology. — The disease is looked upon as purely functional, and no 
organic lesion is present. 

Symptoms. — As there is no known disease or morbid objective symptom 
which cannot be imitated by an hysterical patient, it is readily seen that its 
manifestations are legion. A brief classification of its most prevalent forms 
will be given. 

Motor Symptoms. — Convulsions. — These may be mild, appearing after 
some emotional excitement. The patient laughs and cries alternately, 
feels a "ball" in her throat (globus hystericus), and has painful or peculiar 
sensations resembling an aura. Then comes the convulsion, which subsides 
gradually, usually with the passage of flatus or of a large amount of limpid 
urine. A more severe form, classed as hysteroepilepsy, may be marked by 
excessive convulsive motions and subsequent emotional display, such as 
cataleptic poses, opisthotonus, delirium, and hallucinations (see article on 
Epilepsy for differentiation). 

Paralyses. — Any part of the motor apparatus may be affected, but 
paraplegia is the most common form. Aphonia is frequent. There are 
usually some other symptoms of hysteria combined with the paralysis. 

Contractures may affect any joint. They disappear during sleep or 
chloroform narcosis. Spasms are not uncommon. 

Sensory Symptoms. — There may be irregular areas of anaesthesia and 
hyperaesthesia. Hysterical hemiansesthesia is common. Hyperaesthesia to 
the extent of pain in the head, of an agonizing character, like that of a nail 
being driven into the skull, called hence " clavus hystericus," is not infre- 
quent. The spine, abdomen, and breast are regions for hyperaesthesia. 

Special Senses. — Lessening of the visual field, hemianopia, blindness, or 
change in the perception of colors is seen. Loss of the senses of taste, 
smell, and hearing is common. 

Digestive Symptoms. — "Globus hystericus," spasm of the pharynx 
and oesophagus, vomiting, anorexia, a depraved appetite, gastric pain, re- 
versed peristalsis, flatulence, diarrhoea, and constipation may be hysterical. 

Respiratory Symptoms. — Rapid breathing, dyspncea, extraordinary 
cries and sounds, a dry paroxysmal, barking cough, and spurious haemop- 



HYSTERIA ; HYSTEROEPILEPSY 



729 



tysis may be seen. The blood is of a pale red color and comes from the 
mouth or pharynx, unless deception is practised, for which we must always 
be on the lookout. 

Circulatory Symptoms. — Irritability of the heart, rapid pulse, pain 
over the heart (pseudoangina pectoris), hot flashes and cold chills, pallor, 
flushings (general or localized), circumscribed oedema, and haemorrhages 
in the skin are seen. These latter are usually fraudulent in origin. 

Urinary Symptoms. — After an hysterical attack the urine is abundant, 
watery, and of low specific gravity. Retention is common, but incontinence 
is unknown, which is a diagnostic point between hysteria and true epilepsy. 
Partial or complete anuria may be seen, and during this period the sweat, 
vomit, and other discharges become loaded with urea. Ursemic convul- 
sions never occur in cases of pure hysteria. Bladder and urethral irritation, 
with frequent micturition, is common. 

Joint Symptoms. — Following slight injuries, or without injury, one of 
the larger joints, such as the knee or hip, becomes swollen and flexed and 
resists passive motion (Brodie's joint). However, changes in its position 
may be observed. The skin over the joint may be hyperaesthetic; it is 
usually cool, but at night may be hot and painful. Sometimes, if the con- 
dition lasts long enough, there may be wasting of the muscles and organic 
changes in the joint. 

Temperature. — This is usually normal. Rarely an elevation to from 
102° to 103° is observed, and exceptionally a rise to 108° to 110° has been 
recorded. These high temperatures are probably in some way produced 
fraudulently. Fever with symptoms of peritonitis is occasionally seen. 
Meningitis also may be simulated. 

Mental Symptoms. — Moral perversion, increased irritability, emotional 
exaggerations, impaired self-control, and craving for notice and sympathy 
are manifested. This leads to self-injury, as by swallowing needles, sucking 
blood and vomiting it, and inflicting sores which are not allowed to heal. 
There may be purposeless criminal acts, such as setting fire to houses and 
stealing. Depression is common, occasionally hallucinations may occur, 
and melancholia may be feared. Trance and catalepsy may develop. A 
patient generally has more than one of the many symptoms, and may have 
many. 

Trance is an hysterical condition, developing spontaneously or after some 
hysterical attack, in which all animation is apparently suspended. 

Catalepsy is an hysterical or hypnotic condition (see article on Hypno- 
tism) in which the limbs remain in any position in which they are placed 
for a greater or less length of time. 

Diagnosis. — The diagnosis is made from a study of the general condition, 
and not from a single symptom. 

Prognosis. — The prognosis as to life is very good. The duration depends 
upon the severity of the symptoms and the environment and moral force 
of the patient. 

Treatment. — The physician should make a most careful examination of 
his patient, and exclude organic disease. He should obtain the confidence 
of his patient and let her know that he understands the case. The suffering 
is real, but the patient should not receive too much sympathy, as it is neces- 



730 



THE NERVOUS SYSTEM 



sary to exert self-control as much as possible. Educate the morals and try 
to give mental change. If the home and surroundings are at the bottom 
of the trouble, send the patient away and furnish her with cheerful diver- 
sion. Hydrotherapy, electrotherapy, massage, the rest cure, and mental 
therapeutics may be combined with tonics, such as strychnine, iron, and 
quinine. Treat the symptoms, but never give opium in any form. 

THE TRAUMATIC NEUROSES; TRAUMATIC HYSTERIA 

Traumatic neuroses are morbid conditions which originate with a shock 
and show symptoms of neurasthenia, or hysteria, or both. The name was 
given because the condition was supposed to be due to an inflammation of 
the meninges or the spinal cord. 

etiology. — Although cases develop after an accident, often in a railway 
train, where there is a bodily shock or concussion, the neurosis may arise 
without the shock or concussion. The patient may simply know that there 
has been an accident to the train on which he is riding, or may have seen 
some terrible accident which has sufficed to bring on the symptoms. A week 
may elapse after the accident before the symptoms develop, the patient 
having been perfectly well during this time (railway spine). 

Symptoms. — Simple Traumatic Neurasthenia. — Usually the symp- 
toms develop some days or weeks after the accident, which may have 
done no bodily harm. Headache, insomnia, loss of concentration, irrita- 
bility, despondency, and, in extreme cases, melancholia may develop. In 
fact, all the symptoms of neurasthenia may be present, and according to 
the prevalence of spinal or cerebral symptoms, the name of railway spine 
or railway brain is given. 

Cases with Marked Hysterical Features. — In addition to the neu- 
rasthenic symptoms, there are cases in which the emotions play an im- 
portant part. Self-control is impaired. A striking feature of these cases 
may be a violent bodily tremor. Hemiansesthesia, achromatopsia, and limi- 
tation of the field of vision are among the more frequent hysterical signs. 

Cases in which the Symptoms Suggest Organic Disease op the 
Brain or Spinal Cord. — There may be no fracture or external lesion, and 
yet some time after the injury or shock there may rapidly develop symptoms 
suggesting organic disease. Sensory and motor disturbances are the most 
common, but it is very difficult to distinguish hysteria from real injury. 
" The symptoms upon which the greatest reliance can be placed as indicating 
organic change are optic atrophy, bladder symptoms, particularly in com- 
bination with tremor, paresis, and exaggerated reflexes." Autopsies in 
cases where death follows spinal concussion in a few days may show nothing 
abnormal. In a few instances punctiform haemorrhages have been found in 
the brain and spinal cord. In a few cases where death has resulted a con- 
siderable time after the accident, and the symptoms have been those of 
neurasthenia and hysteria, there have been found sclerotic and softened 
areas in the cord and brain. 

Diagnosis. — It is very difficult to detect a simulator from one who is 
really suffering from a trauma. Under usual conditions, pressure upon a 
really painful spot will increase the pulse rate; if the pain is simulated, the 



INSOMNIA 



731 



pulse rate does not increase. Optic atrophy, bladder trouble, and signs of 
sclerosis of the cord, indicating a degeneration of the lateral columns or 
multiple sclerosis, point toward organic disease. 

Prognosis. — "Traumatic hysteria is one of the most intractable affec- 
tions which we are called upon to treat, but most cases recover." 

The treatment is that of neurasthenia and hysteria. Suggestion has 
probably given the best results. 

INSOMNIA 

Sleeplessness is one of the most frequent conditions which physicians 
in large cities are called upon to treat. We should aim to discover the cause 
and remove it. 

We may class the causes as follows: 

Pain, as with excessive headaches. 

Poisons circulating in the blood, as in acute infections, Bright 's disease, 
hepatic disease, and intestinal toxaemia. 

Insanity, as in melancholia, mania, paranoia, and paresis. 
Ordinary types, seen in nervous people and neurasthenics. 
These cases may be divided into: 
Those with cerebral congestion. 
Those with cerebral anaemia. 

Treatment. — Insomnia due to Cerebral Congestion. — This form is 
recognized by distress and a feeling of distention in the head, muscular 
irritability, and overexcitability. We may endeavor to remove the con- 
gestion in the brain by various means. An enema or laxative may be 
given in the morning. 

There are various forms of hydrotherapy to be tried always before drugs. 
These are to be used just before the patient goes to bed. 

A hot bath sometimes succeeds in causing sleep, but contraction of ves- 
sels is likely to follow soon, and again cause congestion. A cold sponge 
bath after the hot bath seems to prevent this. A good plan is to have the 
patient stand in tepid water which reaches above the ankles, and then wrap 
around the body a dripping sheet from a pail of cold water, at about 80°, 
rubbing the body at the same time. Other resources are the cold pack to the 
abdomen and wearing a flannel cloth wrung out of water at about 75°, cov- 
ered with a dry towel and then with a rubber cloth. The cold flannel soon 
becomes warm, and acts as a poultice, bringing blood to the abdominal cavity. 

Exercise. — Five or ten minutes of calisthenics or exercising with dumb 
bells or Indian clubs before going to bed serve a good purpose, also a brisk 
walk outdoors before going to bed. Forcible respiratory movements, with 
deep inhalations of fresh air, at bedtime are also helpful. 

Drugs. — Bromides are best for cerebral congestion. Give gr. xx to xxv 
about half an hour before the patient goes to bed. A mixture of two or 
three of the bromides, such as bromide of sodium, potassium, ammonium, 
and strontium, seems better than one alone. Chloral hydrate and bromides 
may be combined. Sulphonal and trional should be given with food — 
sulphonal about one hour before bedtime, and trional fifteen to twenty 
minutes before, gr. x to xx, also urethane, 54, and codeine, gr. \, may be 
taken together at bedtime, or hyoscine, gr. x¥T- 



732 



THE NERVOUS SYSTEM 



Suggestion is of great benefit. Autosuggestion, or the suggestion of the 
physician, with a sugar tablet, or a hypodermic injection of sterile water, 
is effective at times. 

Insomnia Due to Cerebral Anaemia. — Patients with this form of 
insomnia usually sleep well at first, but wake up and cannot go to sleep 
again. Stimulation is indicated in these cases and the bowels should 
move regularly. 

Beer, whiskey, or gr. -gV of strychnine at bedtime does well. Chloral 
and chloralamide are good hypnotics in these cases. When a person wakes, 
and cannot fall asleep again, advise him to get up and eat something light, 
or to take a little whiskey, to walk around, or to apply hot and cold water 
to the back. Inhalations of the fumes of whiskey or wine, or of ether, 
alcohol, and cologne, equal parts, on a handkerchief before going to bed 
may help in this class of cases. Opium, as a last resort, is indispensable in 
the insanities. 

HYPNOTISM, OR SUGGESTION; TRANCE 

Hypnotism may be defined as an abnormal mental insensibility to most 
of the sense impressions and excessive sensibility to some impressions. 
There is a certain amount of unconsciousness and an obedience to the 
suggestion of the one who has induced the condition. " It may be regarded 
as an artificial catalepsy." 

The power which one person has over himself and over another, to make 
himself or another do or believe a thing, is a form of hypnotism or suggestion. 
When the physician enters a sick room, sympathetic and in a cheerful mood, 
he knows his power of making his patient comfortable by assurances of an 
improved condition and by removing from the mind unhappy and sad 
thoughts. This is a form of hypnotism or suggestion. 

Many people are using this power of suggestion, consciously and un- 
consciously, and have been for centuries. Parents, teachers, ministers, 
employers, and physicians are constantly using suggestion, but few of them 
could define it or few use it scientifically. It does not take a pathological 
mind or a pathological nervous condition to receive suggestion. Charlatans 
have done an infinite amount of harm through a knowledge of this power. 

As we look back over centuries of history of all countries, we may, under- 
standing the power of suggestion, appreciate the many sects, cults, and 
societies which have had their origin in some minds conscious of this power. 
The present time is replete with examples. A number of scientific men have 
investigated the subject and have learned a great deal. But there is still 
much that we do not understand. 

Hypnotism with partial or complete suppression of consciousness is the 
condition which we usually understand by the word. Bernheim says that 
the majority of people of both sexes and of all ages and temperaments 
can be put into the hypnotic condition. Others maintain that only 
hysterical people and people whose nervous system is not in a proper 
equilibrium can be hypnotized. Bernheim maintains that the profound 
sleep which may be induced by suggestion is not a pathological condition 
or a neurosis analogous to hysteria. 

There are different methods of inducing the hypnotic condition. One is 



CLASSIFICATION OF MENTAL DISTURBANCES 



733 



to have the patient fix his eyes on a bright object, in a manner to tire the 
eye muscles, and, on the operator's suggesting sleep, the patient closes his 
eyes from fatigue, and soon is asleep, or in the hypnotic condition. Bern- 
heim's method is to assure his patients that there is nothing occult or 
mysterious in hypnotism, that it is not harmful or unnatural to produce 
this sleep, and, in order to reassure his patient, he hypnotizes one or two 
patients in his presence. After assuring him and making him believe that he 
can be cured or benefited by such procedures, he gains his cooperation and 
assistance, and puts him to sleep, by merely talking to him in a monotonous, 
sleepy manner, sometimes with the assistance of passes before the face and 
having him fix his gaze on an object, with the purpose of tiring the eyes. 

There are various degrees of intensity of the hypnotic condition. There 
is comprised in these degrees phenomena extending from a simple numbness 
in the simplest forms up to entire unconsciousness of what has transpired 
during the hypnotic condition, catalepsy, automatic movements, contrac- 
tures, hypnotic hallucinations, and posthypnotic suggestions. 

The clinical symptoms which can be cured are mainly neurotic and 
hysterical, but in the larger cities we see such a number of such cases that 
the value of hypnotic suggestion is apparent. The marvelous sudden cures 
of paralyses and other conditions, as at Lourdes and by those so called 
"healers," are probably all hysterical conditions and the healing power is 
suggestion. 



CLASSIFICATION OP MENTAL DISTURBANCES, AFTER KRAEPELIN AND 

MEYNERT 

a. Acquired mental disturbances. 

Acute and chronic conditions of collapse with delirium. 

Acute amentia and dementia. 

Acxite and chronic intoxications. 

Fever delirium, \ . . t , ,. . 

_ . it- r Acute forms ol delirium. 
Poison delirium, j 

Alcoholism, ) 

Morphinism, V Chronic forms of delirium. 
Cocainism, ) 

Metabolic disturbances with insanity, as in myxcedema, cretinism, 

dementia paralytica. 
Insanity with cerebral disease. 
Syphilitic dementia. 
Paretic dementia. 
Senile dementia. 
Alcoholic dementia. 

b. Psychical degeneration in weak brain or maldeveloped brain. 

Periodical psychoneuroses, confusional, emotional, impulsive, depress- 
ive (melancholic) forms, with imperative ideas or sexual perversions. 
Maniacal forms — dementia prsecox. 
Paranoia. 
Epileptic insanity. 
Imbecility, idiocy. 



734 



THE NERVOUS SYSTEM 



VASOMOTOR AND TROPHIC DISTURBANCES 

GENERAL REMARKS 

The nutrition of a part is governed by the nervous system. A dis- 
turbance of this part of the nervous system results in disorders designated 
as trophic disturbances or trophic neuroses. Hypertrophy or atrophy of 
nerves, muscles, and cutaneous and mucous tissues, joint degeneration, and 
various skin eruptions are examples of trophic neuroses. If joints are 
affected, we speak of arthropathies; if muscles, atrophies, hypertrophies, and 
dystrophies; if nerves, degeneration; if fat is substituted for atrophy, or 
associated with atrophy, we call it lipomatosis or fatty degeneration, as in 
some dystrophies. Herpes, pemphigus, and other eruptions, pigmentation, 
leucoderma, non-parasitic alopecia, and bedsores are examples of tropho- 
neuroses of the skin. 

The nerves which supply the blood vessels and the glands maybe affected, 
and produce a variety of symptoms. Vessels and glands may be affected 
separately, but usually both are affected by the same neurosis. 

Angeioneurosis designates a disorder of the vasomotor centre and nerves. 
Angeiospasm is applied to the condition where there is a spasmodic con- 
traction of the muscular coats of the arteries with an increase in the vaso- 
motor tone. Angeioparalysis represents an opposite condition. Pallor and 
coolness, and flushing, and heat are the results of such conditions of spasm 
and paralysis. 

Secretory Neuroses. — The skin is the part of the body which most 
often shows this disturbance. 

Hyperidrosis is an excessive sweating. Anidrosis is an excessive dry- 
ness. Paridrosis is a perversion of the perspiratory secretion. We may 
notice peculiar odors and colors to the perspiration. Hwmidrosis is bloody 
sweating. 

RAYNAUD'S DISEASE 

This is a rare disorder, probably due to a vasomotor disturbance. 

^Etiology. — It occurs most often in children and young women. Anaemia, 
chlorosis, and neurasthenic conditions seem to create a predisposition. 
Malarial infection, acute infectious fevers, menstrual disorders, fright, and 
occupations that lead to exposure, such as washing, seem to be exciting 
causes. Diabetes and syphilis are underlying causes. The disease comes 
on rather suddenly and affects most often two or three fingers of both hands. 
There are three grades of intensity: 

1. Local syncope is the most common form. There are coldness and 
pallor of the extremities (called "dead fingers" or "dead toes") which 
can be induced by cold or emotions. The affected parts are stiff and some- 
times painful. There is a waxy pallor; the skin looks shrunken, and there 
is slight anaesthesia. After a few hours this passes away but returns again 
and may become almost a constant condition. 

2. Local asphyxia may succeed these conditions, or the disease may 
appear first in this manner. The affected parts, fingers, toes, ears, and nose, 
become livid and cyanosed. There are numbness, swelling, and some pain. 
The capillary circulation is exceedingly sluggish. Upon the attack wearing 



SYMMETRICAL GANGRENE 



735 






off, the parts become bright red from the overactive circulation. Local 
gangrene may follow severe attacks. Recurrences are common, especially 
during cold weather. There may be much 
pain in this stage, but no anaesthesia. Gan- 
grene may follow. 

3. Local or Symmetrical Gangrene. — 
Spots of ecchymosis and vesicles appear, and at 
these points a symmetrical gangrene develops. 
The ears, fingers, and toes are the usual situa- 
tions. Usually the part becoming gangre- 
nous is small, and when it heals it leaves a 
scar. Rarely the whole tip of the finger or 
toe may be involved and separated. Purpura 
hsemorrhagica, intermittent haemoglobinuria, 
peripheral neuritis, and a variety of mental 
and cerebral symptoms may complicate the 
disease. The gangrenous stage lasts about 
three weeks. 

Differential Diagnosis. — We have to dis- 
tinguish from frostbite, senile gangrene, ergot 
poisoning, alcoholic neuritis, endarteritis, and 
obstruction of the nutrient vessels. 

The prognosis is good except where there is 
extensive gangrene and in the gangrenous cases 
complicated by purpura hsemorrhagica, etc. 

Treatment. — Avoid exposure to extreme 
cold. If possible, spend the winters in a 
warm climate. Galvanism to the 
spine and limbs, warm applications, 
anodynes, and tonics are indicated. 
Internal medication seems to do no 
good, but we may try nitroglycer- 
ine, the iodides, and chloral. 

ERYTHROMELALGIA 

Erythromelalgia is a very rare 
chronic disease characterized by se- 
vere pain, flushing, and local heat, 
usually in one or more extremities. 
The pain is intensified if the part 
hangs down. It affects the feet 
chiefly. It occurs usually in men 
of middle life after a low fever or 
severe physical exertion on the feet. 

The disease develops gradually from dull pain, worse at night, in the 
ball of the foot to an almost continuous pain of the whole region supplied 
by the plantar nerve. The affected part later assumes a dull, dusky, 
mottled redness. The congestion and pain usually disappear when the part 





Fig. 213. — Symmetrical Gangrene. 

Raynaud's Disease or Endarteritis Obliterans. 
(J. D. Morgan.) 



736 



THE NERVOUS SYSTEM 



is in a horizontal position. Although the disease is not necessarily fatal, 
it makes life miserable. 

The diagnosis is to be made from alcoholic and gouty paresthesia?, 
podalgia, local diseases of the bone and ligaments, and reflex pains. 

Treatment is very unsatisfactory as to cure Temporary relief is ob- 
tained by elevation of the feet and applications of cold. Faradization has 




Fig. 214. — Hemiatrophia Facialis Progressiva. 
Archives of Pediatrics, 1899. (Dr. F. Huber.) 



helped in some cases. Rest, bandaging, cold, anodyne applications, hydro- 
therapy, and tonics may be tried. 

FACIAL HEMIATROPHY 

Facial hemiatrophy is a rare condition, often congenital, usually begin- 
ning in childhood, and characterized by atrophy of one half of the face. 



GENERAL DIAGNOSTIC AND THERAPEUTIC REMARKS ON MENINGITIS 737 



The pathology is not known. 

Symptoms. — In childhood usually, a small area of atrophy begins on 
the cheek or chin and gradually spreads so as to involve one half of the face 
and scalp, being sharply limited at the median line. Although the change 
in the muscles is slight, the bones and other deeper structures share in the 
atrophy. Pains and peculiar sensations may be present at first. The tongue 
and palate may show atrophy on one side. The left side of the face is most 
often involved. 

Prognosis. — Recovery has never been seen, but the disease is not serious 
as to life. It progresses slowly, but the process may be arrested at any time. 

Treatment. — Although it is incurable, tonics and operations upon the 
fifth nerve have been tried. 

Other trophoneurotic manifestations are angeioneurotic ccdema (see 
(Edema), acromegaly (see Disease of the Ductless Glands), mal perforans, 
perforating ulcer (see Locomotor Ataxia), trophic diseases of the extremi- 
ties and joints (see Joints), herpes and scleroderma (see Dermatological 
Memoranda) . 

MENINGITIS IN ADULTS 

(For Meningitis in Children, see Pcediatrics) 

GENERAL DIAGNOSTIC AND THERAPEUTIC REMARKS 

The meninges respond to irritation like other serous membranes, and 
may become the seat of primary or secondary inflammation, accompanied 
by serous or purulent effusion. The same species of microbe which pro- 
duces a pneumonia or pleurisy may start a meningitis or synovitis, accord- 
ing to its localization. The infecting agent may reach the meninges through 
the blood, or by extension from the nasopharynx, the ear, or the eye. 
Meningeal symptoms, such as delirium and slight rigidity of the neck, are 
often observed in acute infectious diseases. These are toxic (toxsemia) 
phenomena, and must not be confounded with true meningitis. 

The ordinary clinical varieties are: 

1. Leptomeningitis (acute and chronic). 

2. Tuberculous ) j^ en ^ n 

3. Cerebrospinal \ b 

4. Pachymeningitis (acute and chronic). 

Differential Diagnosis. — In discriminating between the various forms 
of meningitis, it will be well if we bear in mind that all the symptoms spoken 
of are the usual ones of a group of pathological conditions which we class 
under the heading of encephalomeningitis, whose aetiology embraces a 
variety of causes: 

1. Primary microbial infection, including the tuberculous variety. 2. 
Secondary microbial infection, following any form of acute or chronic in- 
fection, including syphilis and favored by alcoholism. 3. Extension of a 
neighboring inflammatory process of the ear or nose, panophthalmitis, intra- 
cranial abscess, tumors, etc. 

Symptoms and Signs of Meningitis in General. — General malaise, drowsi- 
ness, vomiting, constipation, stiff neck and back, loss of control of the 
bladder and rectum, convulsions, delirium, coma, and set eyes. 



738 



THE NERVOUS SYSTEM 



The temperature ranges from 101° to 105°, 106°, 107° F., or higher. The 
pulse at first is rapid, then irregular and slow. Cheyne-Stokes respiration 
is often seen. 

When we are face to face with illness in which meningeal symptoms are 
noticeable, the first practical and important point is to decide whether or 
not there is meningitis. The question cannot be decided by taking into 
consideration any group of symptoms. A careful weighing of all the evi- 
dence is necessary. 

Vomiting, delirium, muscular rigidity, as symptoms of toxaemia, are just 
as pronounced in some cases of pneumonia, influenza, or eruptive fevers 
as in acute true cerebral or spinal meningitis. Malaise, vomiting, constipa- 
tion, low muttering, grinding of the teeth in sleep, injected conjunctiva, 
irregularity of the pulse, and sighing respiration are symptoms of long stand- 
ing intestinal inertia and autoinfection, as well as symptoms of tuberculous 
meningitis. 

In meningitis we can generally elicit the tdche meningitique, or Trousseau's 
sign, by drawing the finger nail sharply over the skin. Owing to vasomotor 
disturbances the red irritation mark comes slowly and disappears slowly. 

Kernig's Sign. — In cases of meningitis it is usually impossible for a 
patient lying on his back to flex the thighs upon the body without flexing 
the knee at the same time, and complete extension of the legs is impossible. 

Both Trousseau's and Kernig's sign are occasionally found in patients 
not suffering from meningitis, and their absence does not positively exclude 
the diagnosis of meningitis. 

Spinal Puncture. — The cerebrospinal fluid obtained by puncturing the 
spine is cloudy or turbid in acute meningitis. In several cases of meningitis 
the writer has withdrawn pure pus by spinal puncture repeatedly. 

In tuberculous meningitis the fluid is very clear. The tubercle bacilli 
can seldom be found in the fluid by microscopical examination. If present, 
they are detected by the culture and inoculation tests. For modus operandi 
of spinal puncture see chapter on Dropsy and Effusion. 

Treatment of Meningitis in General. — Order an ice coil to the head, warm 
mustard baths, and cool sponge baths; fever diet (milk, gruels, broths, tea, 
beef tea, and eggs); inunctions of mercurial or Crede's ointment, 3j twice 
daily; a daily enema of soap water or salt water, one ounce to one pint; 
catheterism of the bladder in cases of retention of urine; feeding by gavage 
in coma; feeding per rectum; spinal puncture to relieve pressure symptoms; 
stimulation p. r. n. or sedatives; and tincture of iodine to check vomiting, 
one drop in sweetened peppermint water every two or three hours. 

Local Treatment. — In tuberculous meningitis local treatment has 
been attempted by the author by injecting iodoform, potassium iodide, and 
sodium salicylate into the subarachnoid space without beneficial results. 
Cases of cerebrospinal meningitis frequently recover after the administra- 
tion of salicylate of sodium and bromide of potassium internally and the use 
of Crede's ointment externally by inunction (twice daily). The writer is 
unable to state whether or not Crede's ointment has any therapeutic value. 



FORMS OF MENINGITIS 



739 



ACUTE AND CHRONIC LEPTOMENINGITIS IN ADULTS 

Acute Cerebral Leptomeningitis 

^Etiology. — A germ infection is regularly at the bottom of inflammations 
of the pia. The more common way of infection is secondary through some 
purulent process of contiguous parts or from distant parts through the 
circulation. 

1. Primary Form. — The origin is not known. 

2. Direct extension may follow an inflammation or injury of the bones 
of the skull, dura, or orbital cavity. Middle ear disease, with necrosis of 
the petrous portion of the temporal bone, is the most frequent cause. An 
infection through the cavernous sinus, from phlebitis arising from suppura- 
tion of the orbit or cheek, may be a source. From a disease of the nose 
causing frontal sinus suppuration or necrosis of the cribriform plate the in- 
fection may travel to the meninges. Germs may also travel along the nerve 
sheaths during the course of facial erysipelas. 

3. Through the arteries infection may be carried during pyaemia, 
from an abscess of the lung or from malignant endocarditis. The infection 
may take place during the infectious diseases, such as pneumonia, rheu- 
matism, and the exanthemata, but especially during pneumonia, erysipelas, 
or septicaemia. Bright 's disease and gout seem to favor meningeal infec- 
tion, and it may be a terminal infection in these, as also in arteriosclerosis, 
heart disease, and the wasting diseases of children. There is a predisposi- 
tion from the congestion which follows sunstroke. 

Pathology. — We distinguish two forms: Cellular and exudative. Cel- 
lular meningitis shows the pia congested, dry, and lustreless, with cellular 
infiltration of its substance. No exudate is present. Exudative meningitis 
shows throughout the thickened pia, within the meshes, collections of fibrin, 
serum, and pus. Occasionally the exudate collects on the surface. The 
ventricles are likely to become inflamed and distended in children and young 
adults. By direct extension, there may occur inflammation of the pia mater 
of the spinal cord. There are likely to be different inflamed areas according 
to the mode of infection. With middle ear disease the process is over the 
temporosphenoidal lobe of one side. With pneumonia and malignant en- 
docarditis the process is likely to be bilateral and limited to the cortex. In 
other cases the base of the brain alone may be involved. When the ven- 
tricles are involved, the distention from inflammatory exudation may 
persist for some time. 

Symptoms. — Prodromal. — These are conjunctivitis, headache, irritabil- 
ity of temper, sleeplessness, nausea, vomiting, and general malaise. The 
invasion -may be more sudden, with fever, headache, convulsions, de- 
lirium, and vomiting. After the disease is established we observe the 
symptoms of brain irritation. The temperature varies, with irregular re- 
missions. The headache is continuous and severe. Restlessness and stupor 
are the most pronounced symptoms throughout the disease. One or the 
other may predominate, and they may alternate. All degrees of each are 
seen. Supersensitiveness, localized or general, may be severe. Tenderness 
and stiffness of the muscles of the neck are present if the inflammation 



740 



THE NERVOUS SYSTEM 



extends down to the pia mater of the cord. Involuntary contractions of 
groups of muscles, especially those of the face, are often present. Some- 
times there may be convulsions, unilateral or general. 

The roots of the cranial nerves may be involved in the inflammatory 
process, and as they become affected, we observe symptoms of their 
irritation, such as photophobia, blindness, strabismus, painful hearing, and 
deafness. 

Vomiting may continue, or it may not appear until later. The tongue 
is coated and dry in the severe cases. Usually the patient is constipated, 
but there may be diarrhoea and involuntary movements in the last days of 
fatal cases. The quantity of urine is diminished and it is likely to contain 
casts and albumin. The pulse is rapid with cortical irritation. 

The symptoms of brain compression follow. These are due both to the 
thickening of the pia and to distention of the ventricles. There are dulness, 
apathy, and blunting of the special senses. Stupor and coma are more 
likely to be seen than restlessness. There may be paralyses now of groups of 
muscles, or general paralysis. The pulse is now slowed and may be irregular. 
The coma becomes profound, the paralysis more marked, and in the latest 
stages the pulse becomes rapid and feeble, while the breathing may be of the 
Cheyne-Stokes variety. 

In children there may be the same course as in adults, but from the 
greater likelihood of distention of the lateral ventricles, the symptoms may 
differ. Some children have for the principal symptoms fever and alternat- 
ing convulsions and stupor. In others the course is like that of tuberculous 
meningitis. 

When the inflammation is secondary to otitis or a similar preceding 
condition, or when it complicates some general infection, we observe the 
symptoms of these affections first, with the meningeal symptoms developing 
later. We must remember, however, that there may be complicating 
cerebral symptoms (pseudomeningitis) without meningitis, and the only 
difference between these and those of meningitis is that the latter are more 
marked and severe. 

The duration is ordinarily from one to two weeks, but we may have 
cases lasting from thirty-six hours to four weeks. 

The prognosis is bad, but not hopeless. 

Treatment. — Prophylaxis consists in the proper management of middle 
ear disease and diseases of the face, orbit, and nose. After the disease is estab- 
lished, diminish the severity of the inflammation in the early stages, alleviate 
the pain, and give sufficient nourishment. 

Cold should be continuously applied to the head by means of a coil or 
ice cap. Bloodletting from the temples and back of the neck and the appli- 
cation of leeches behind the ears is indicated in the early stages.. Calomel 
and magnesium sulphate at the outset, in sufficiently large doses to move 
the bowels freely, reduce the meningeal congestion. Ergot and potassium 
iodide are also used to reduce the congestion. 

The headache and restlessness may be controlled by opium, phenacetin, 
chloral, bromide of sodium, and sulphonal. The patient should be kept 
quiet, free from noise, and in a darkened room. Operative interference 
should be practised in the cases where an abscess can be localized. 



CHRONIC MENINGITIS (CHRONIC LEPTOMENINGITIS) 741 



Acute Spinal Leptomeningitis 

This is a rare inflammatory disease. It may occur alone, but it is 
usually seen in connection with cerebral leptomeningitis. 

^Etiology. — As an extension from the brain, it may be a simple or 
epidemic inflammation. It may result from an injury to the vertebrae, as 
from an operation. Acute infectious diseases, especially pneumonia, small- 
pox, scarlet fever, and typhoid fever, may be complicated with this disease. 
The inflammation may be tuberculous in character. Cases supposed to be 
due to wet, cold, and insolation are probably due to some germ infection. 
The germs of epidemic cerebrospinal meningitis may affect the cord alone. 

Pathology. — Although the inflammatory process is usually distributed 
throughout the length of the cord, it may be localized at different levels. 
The nature of the exudate depends upon the causative factor. It is usually 
more abundant at the posterior portion of the cord, owing to the usual 
position of the patient (in bed, lying on his back). The peripheral portions 
of the cord are usually infiltrated by the inflammatory products, and the 
nerve roots are surrounded and compressed by them. Most cases show 
corresponding lesions in the pia mater of the brain. 

Symptoms. — At first we observe the symptoms of irritation of the spinal 
nerves, pain in the back, pains shooting along the course of the nerves, areas 
of hyperesthesia, and spasm and rigidity of the muscles supplied by the 
nerves irritated. We find rigidity of the spine, with the head thrown back, 
and sometimes opisthotonus. The larynx may be so firmfy pressed against 
the spinal column, from the retraction of the head and neck, as to cause 
stridor and obstructive dyspnoea. There is usually an exaggeration of the 
reflexes, and there may be retention of urine. There is always an irregular 
fever, seldom higher than 104° F. When pressure takes place from an 
accumulation of the inflammatory products, we note anaesthesia, complete 
paralysis, and atrophy. The reflexes are lost, the sphincters are paralyzed, 
and bedsores may take place. 

Differential Diagnosis. — We must distinguish the disease from myelitis, 
rheumatism of the dorsal muscles, and gonorrheal rheumatism. Myelitis 
causes very little pain and much paralysis. In tetanus, there is trismus, 
without fever and with the history of an injury. Tuberculous meningitis 
comes on more slowly and is usually associated with a cerebral process, 
and there may be signs of tuberculosis in some other part of the body. 

The prognosis is not good. It is particularly bad in cases of tuberculous 
origin and in cases where there are high fever, severe pain, and early paral- 
ysis. The acute symptoms may subside and leave a chronic meningitis. 

Treatment. — Rest, quiet, leeches along the spine, then hot poultices or 
ice bags are to be used. Mercurial purges and small doses of potassium 
iodide or of sulphate of magnesium may be given at short intervals. Later, 
blisters, counterirritation, and lukewarm baths are indicated. 

CHRONIC MENINGITIS (CHRONIC LEPTOMENINGITIS) 

Chronic meningitis is a rare disease. It is seen in middle age and in those 
who have been deprived of the necessities of life and much exposed. Tramps 



742 



THE NERVOUS SYSTEM 



and the inhabitants of almshouses are among those affected. Alcoholism 
and cerebral endarteritis seem to lead to the disease. It may complicate 
chronic Bright's disease, chronic degeneration of the brain, slow growing- 
cerebral tumors, chronic pachymeningitis, or fractures and inflammations 
of the cranial bones. 

Pathology. — The pia mater, in parts or as a whole, may be thickened, 
opaque, cedematous, and infiltrated with cells. Adhesions may be present 
between the pia and dura, and the cortical portion of the brain may show 
softening or sclerosis. The ependyma of the ventricles may be thickened 
and roughened, and the ventricles themselves dilated and distended with 
serum. 

The symptoms resemble those of chronic pachymeningitis. At first 
they are obscure and intermittent, making the diagnosis difficult and 
sometimes impossible. The final symptoms are those of brain compression. 

The prognosis is not good and recovery cannot be expected. The dis- 
ease extends over a number of years and results in insanity, or else the 
patients die with marked cerebral symptoms or in a condition of exhaus- 
tion and emaciation. 

Treatment. — Syphilis should be excluded by a treatment with mercury 
and iodide of potassium. Otherwise we can only alleviate the symptoms. 

Chronic Leptomeningitis Spinalis 

^Etiology.- — It may remain after an acute process, or originate as a 
chronic process, when it may be due to syphilis or alcoholism. It may 
complicate such diseases of the cord as extend to the membranes, or proceed 
from without, as from tumors or disease of the vertebrae. 

Pathology. — If the process has been acute, the lesions are likely to be 
extensive; if it has started as a chronic process, it is usually limited. There 
is a productive inflammation, with thickening of the pia and adhesions to 
the cord and to the dura. The nerve roots may be compressed and even 
atrophied. The productive inflammation may invade the cord in an annular 
form, and it rarely affects the fibres. This is called meningomyelitis. 

Symptoms. — They are the same as in the acute form, except that the 
muscular spasm is less prominent. There are pain in the back, increased on 
movement, radiating about the trunk and down the limbs, tenderness over 
the spine, stiffness of the back, some twitching of the limbs with weakness, 
and later anaesthesia, paralysis, wasting, and bladder weakness. There 
may be cutaneous eruptions, such as herpes. We frequently observe also 
the symptoms of a primary disease within or without the cord. 

Differential Diagnosis. — We must distinguish this disease from spinal 
irritation, locomotor ataxia, myelitis, vertebral caries, and torticollis. We 
do not observe in spinal irritation the rigidity, severe radiating pains, 
twitchings, atrophy, or paralysis, and we do observe symptoms of hysteria 
or neurasthenia. In locomotor ataxia the knee jerk is lost, and there is 
ataxia, with little paralysis and no tenderness over the spine. In vertebral 
caries there are much more localized pain and tenderness and a spasmodic 
fixation of the trunk. The quality of the pain is dull and more continuous. 
It is lessened by extension and increased by lateral pressure. Usually there 



CEREBROSPINAL MENINGITIS IN ADULTS 



743 



is some deformity. But there may be a local meningitis with caries of the 
vertebrae. 

The prognosis is not good, and we cannot look for recovery. However, 
the patient may live for years. 

Treatment. — Rest is the most essential feature. Persistent and sys- 
tematic counterirritation, as with the actual cautery and cupping, may be 
of benefit. For drugs, we may give potassium iodide, small doses of the 
bichloride of mercury, nitroglycerine, digitalis, the salicylates, and ergot. 
We may also try galvanism, local injections of cocaine, and cataphoresis. 

CEREBROSPINAL MENINGITIS IN ADULTS 

Synonyms: Cerebrospinal fever, malignant purpuric fever, petechial fever, 
spotted fever. This is an infectious disease caused by the Diplococcus intra- 
cellularis. It may occur epidemically or sporadically, and is character- 
ized by an inflammation of the cerebrospinal meninges. 

jEtiology. — Although the Diplococcus intracellulars is recognized as the 
cause of the inflammation, the manner in which it enters the system is un- 
known. The epidemic form occurs in certain regions, seldom widespread, 
and more often in the country than in the city. Winter and spring are the 
seasons when the outbreaks have taken place, and poor hygiene, crowding 
together of people, overexertion, long marches in the heat, and depressing 
mental and physical surroundings seem to be predisposing factors. Recruits, 
young soldiers in barracks, children, and young adults are most often 
affected. The disease does not seem to be contagious through personal 
contact, nor through fomites, and it is very rare to have more than one 
case in a house. The sporadic form occurs in both the city and the country. 

Pathology. — In the brain the usual changes found in the acute cases are 
congestion, the veins and sinuses being gorged with blood, and more or less 
infiltration of the pia mater with an exudate of fibrin, serum, and pus. We 
may find this infiltration confined to the base or more generally distributed. 
Along the course of the blood vessels and in the sulci the exudate is more 
abundant. We find the lateral ventricles filled with serum or a seropurulent 
exudation. This may distend the ventricles, particularly in children, and 
continue to do so after the inflammation has subsided, in chronic cases, 
constituting chronic hydrocephalus. In malignant cases we may find 
merely extreme congestion. We often find the brain cortex infiltrated 
with pus, leading to small abscesses. The cranial nerve sheaths, particularly 
those of the second, fifth, seventh, and eighth nerves, being involved in the 
process, may lead to neuritis and perineuritis. 

The pia mater of the cord shows similar changes, which, from gravity, 
are found particularly on the posterior aspect of the cord. The cerebro- 
spinal fluid, usually increased in amount, is turbid and contains the 
Diplococcus intracellular is, as well as frequently other pyogenic cocci. 

The nature of the inflammation is sometimes unproductive in character, 
and then there is no serum, fibrin, or pus. The pia mater in these cases 
may look normal, or it may be lustreless or congested. In the cases running 
a more chronic course we find the meninges thickened, and there are yellow 
patches which mark the former location of the exudate. Pathological 
48 



744 



THE NERVOUS SYSTEM 



changes in other parts of the body are not peculiar to this disease, as they 
are either common to all infectious diseases or due to some complication. 

Symptoms. — Malignant Form. — The onset is sudden, with a chill, 
headache, high or moderate fever, somnolence, muscular spasms, and great 
depression. The pulse is feeble and frequently slow. Hemorrhagic spots 
usually appear on the skin. The cerebral symptoms develop rapidly. 
Death may occur in a few days. Although this severe form is usually seen 
in epidemics, it may occur sporadically. 

Ordinary Form. — The incubation period is not certainly known, but 
there may be general malaise for a few hours or days. Usually the onset is 
sudden, with headache, chill, fever, and vomiting. The fever is variable, 
but usually only moderate, from 101° to 104° F. In some cases the tem- 
perature rises to 108° F. and drops to 97° F. The pulse is usually full 
and strong, although a high temperature may be associated with a rapid 
pulse. It varies greatly. The headache is a prominent symptom and is 
severe. It is usually occipital, but may be parietal, frontal, or general. 
The pain extends into the back of the neck and may extend into the back. 
There may be areas of exquisite hypersesthesia, and particularly there is 
sensitiveness along the spine. General pains in the bones or muscles are 
noticed. Vomiting is a severe and distressing symptom, and it has no 
relation to ingestion of food or drink. It may be projectile in character. 

The nervous symptoms of irritation are prominent. One of the important 
early symptoms is a painful stiffness of the muscles of the neck. Opisthot- 
onus may be present, but it is more common to observe orthotonus. The 
slight forward bending of the head, the " cranelike neck," has recently been 
mentioned as a diagnostic symptom. Twitchings and spasms of the muscles 
and automatic movements of the muscles of the arms or legs are frequent. 
Kernig's sign is usually present. It consists in the inability to extend the 
leg to a straight line on the thigh when the thigh is held at right angles to 
the body. Babinsky's reflex is often present, but it may be present in 
other conditions. It is obtained by stroking the sole of the foot, which 
causes extension of the great toe. In health this irritation will cause 
flexion of the great and second toes or a rapid withdrawal of the whole 
foot and leg. It is characteristic to observe exaggerated reflexes. 

Irritation of the cranial nerves causes photophobia, often associated with 
conjunctivitis, intolerance to noises, facial neuralgia, and facial twitchings. 

For psychical symptoms, we observe delirium, which may be maniacal. 
Morbid erotic desires may be present, and from time to time there may be 
a sudden sharp cry, the " hydrocephalic cry." 

Eruptions on the skin are not at all regular. There may be herpes 
on the lips or face, the serum of which may contain the bacteria causing 
the disease. Erythematous blotches, urticaria, or petechial spots may be 
present. 

Albumin and casts are usually found in the urine, and polyuria and 
glycosuria have been present in some cases. 

The bowels are usually very constipated, but a few cases have been seen 
with dysentery. The " boat-shaped " abdomen, due to marked retraction 
of the abdominal muscles, is often noted. Some patients have severe ab- 
dominal pain. 



CEREBROSPINAL MENINGITIS IN ADULTS 



745 



Leucocytosis is an early and constant feature. The white blood cells 
average from 25,000 to 40,000 to the cubic millimetre. 

Later in the disease we note the symptoms of pressure. There is no 
complaint of headache, but from the moanings and motions we know that 
it is present. Dulness and apathy increase to stupor and coma. However, 
there may be periods of low muttering delirium. Photophobia is succeeded 
by the inability to perceive light. The pupils are usually dilated; no atten- 
tion is paid to noises; muscular weakness and paralysis succeed the twitch- 
ings, and this is most marked in the face and eye muscles, causing strabis- 
mus. The temperature continues irregular; the pulse is usually slow, but 
toward the end becomes rapid and feeble; the respiration may be irregular 
or of the Cheyne-Stokes variety. Toward the end there may be diarrhoea 
and loss of control of the sphincters. There may be an ante mortem 
hyperpyrexia. Cases recovering exhibit a rapid improvement, but usually 
a long convalescence characterized by headache, insomnia, weakness and 
pains in the legs and joints, mental dulness, and sluggishness in movements. 

Course. — The course of the disease varies greatly. More than half the 
patients die within the first week. If the case is favorable, improvement 
generally begins in five or six days, and the worst symptoms improve 
rapidly. Convalescence is very slow and tedious as a rule, and may be 
interrupted by sequelae and complications. 

Anomalous Cases. — 1. In young babies convulsions are a prominent 
symptom throughout the course, the fever is high, the pulse is rapid, and 
stupor alternates with restlessness. Death takes place in coma. 

2. Mild Cases. — Headache, nausea, vertigo, a little fever, possibly stiff- 
ness of the neck, and vomiting make a form difficult to diagnosticate except 
during epidemics. 

3. Intermittent Cases. — In these cases there are periods of improvement 
and remission of fever which may last from a few hours to a few days. These 
periods may be regular and make one think of malaria or pyaemia. 

4. The abortive cases begin in the regular way, and seem severe, but after 
a few days there is a sudden change for the better and the patient improves 
rapidly. 

5. A chronic form has been described as being relatively frequent. An 
attack may have a most complex symptomatology, lasting five or six months, 
showing a series of recurrences of fever, and cause severe marasmus. A 
chronic hydrocephalus or abscesses of the brain may be the cause of this 
protraction. 

Complications. — Lobar pneumonia is a frequent complication, and 
bronchitis, pleurisy, pericarditis, and parotitis are not uncommon. En- 
docarditis is sometimes seen. 

We usually see conjunctivitis, but purulent keratitis or chorioiditis, 
with loss of sight, or optic neuritis with atrophy may occur. The eye com- 
plications are due to involvement of the nerves, which causes neuritis, or 
the inflammatory process may travel along the sheath of the optic nerve. 
Deafness and otitis media with mastoiditis may occur. 

Coryza is frequently an early symptom, and some allege that it may 
precede the meningitis, which might lead us to think that the infection en- 
tered through the nasal mucous membrane. 



746 



THE NERVOUS SYSTEM 



Arthritis occurs in some epidemics. We observe painful, red, swollen 
joints, with effusion within and around. Sometimes the exudate is purulent. 

Sequelas. — Chronic hydrocephalus, prolonged prostration, gastric irrita- 
bility, protracted headache, dilated pupils, mental weakness, forgetfulness, 
and anaemia are seen. A neuritis may result in a paralysis. There may be 
partial or complete blindness, from atrophy of the optic nerve, corneal 
ulcerations, or chorioiditis. Permanent deafness, and in children deaf- 
mutism, may be the result of a meningitis. 

Diagnosis. — The most important signs are fever, headache, delirium, 
retraction of the neck, tremor, and rigidity of the muscles, but we notice 
these symptoms in some cases of typhoid fever and pneumonia. In some 
babies with severe bowel troubles we observe symptoms of meningeal 
irritation. 

Kernig's and Babinsky's signs have been spoken of. 

Lumbar puncture will furnish us with a specimen of fluid for microscopical 
examination. There is usually no difficulty in determining between the 
pneumococcus and the Diplococcus intracellular is. If the fluid shows no 
bacteria, we may inoculate it into a guinea pig. Tuberculosis can thus be 

diagnosticated. 

Method of Procedure in Lumbar Puncture. — The patient is turned on 
the right side with the back bowed, the knees drawn up, and the left shoulder 
forward. We may use a local anaesthetic or a few whiffs of chloroform. 
Under the strictest antiseptic precautions, we insert a small aspirating 
needle or an antitoxine needle about one centimetre to the right or left of 
the median line, in the third lumbar interspace, guiding it upward and in- 
ward. The needle enters the cord at a variable depth from the surface of 
the body, according to the age of the individual and the musculature, from 
2.5 to 6 cm. The fluid runs drop by drop as a rule, and if there is menin- 
gitis, it is likely to be turbid, may be purulent, and sometimes is bloody. 
Even if it is clear, meningitis may be present. 

The prognosis is bad, but not hopeless. It depends on the severity of 
the symptoms, especially those of cerebral origin, and also on the character 
of the epidemic. The mortality in different epidemics ranges from 20 to 
75 per cent. The average mortality is about 40 per cent. Deep coma, 
repeated convulsions, and high fever are the pronounced symptoms of 
fatal cases. The endemic cases are usually not so severe as the epidemic 
cases. 

Treatment. — All that we can do apparently is to relieve suffering and 
treat the symptoms. If the patient is robust, local blood letting by means 
of leeches applied to the temples or behind the ears, or the application of 
wet cups to the nape of the neck, is of benefit sometimes. The continuous 
application of cold by means of the coil or ice bags to the head and spine 
usually gives relief. Lumbar puncture, if properly done, is harmless and 
may be of benefit. Hydrotherapy, including warm baths, may be indicated 
by high temperatures. Potassium iodide is used throughout the disease 
for its absorbent action. It is given in 20 grain doses three times a day. 
Salicylate of sodium may be given in 30 grain doses three times a day by the 
mouth or per rectum. The nervous symptoms demand sedatives. Bromide 
of sodium, hyoscyamine, phenacetin, atropine, and morphine are used. 



TUBERCULOUS MENINGITIS IX ADULTS 



747 



Drug stimulants and enteroclysis must be used where heart weakness is 
evident. 

A nutritious diet, consisting of milk and strong broths during the fever, 
must be maintained. Forced alimentation by means of the stomach tube 
may be employed in suitable cases. 



TUBERCULOUS MENINGITIS IN ADULTS 



DIFFERENTIAL TABLE 



Tuberculous Meningitis 
History of tuberculosis. 
No apparent cause. 
Longer prodromal period. 
Longer course. 

Presence of tuberculosis in the 

or elsewhere. 
Heredity in 20 per cent. 



Simple Meningitis 
History of ear disease, etc. 
Cause evident. 
Short prodromal period. 
Short course, 
igs No tuberculosis. 

No heredity. 



The pathological changes in adults are the same as in children, except 
that in adults it is the exception for the ventricles to be involved. It may 
be a part of a general tuberculosis, but is usually a localized process, either 
primary or secondary to a focus elsewhere in the body. 

Symptoms. — Some cases show only symptoms of the general tuberculosis, 
although there exists the meningitis. In some cases marked symptoms of 
meningitis develop suddenly where apparently there has been previous good 
health. Some of these are undoubtedly primary cases of tuberculous 
meningitis, while in others there was somewhere in the body a tuberculous 
focus from which the infection was carried to the head. 

If the invasion is sudden, there is a chill, followed by headache, pro- 
jectile vomiting, and prostration. If the invasion is gradual, there is a 
little fever, with headache, loss of appetite, and general malaise. When 
the disease is established, we observe the typical picture described under 
acute meningitis. The symptoms may be severe, and the patients die in 
from one to two weeks; or they may be less severe, with intervals of improve- 
ment, and linger from three to seven weeks. In some cases the meningitis 
develops during the course of a pulmonary tuberculosis. 

The prognosis of tuberculous meningitis in adults is not good, but some 
patients with these symptoms recover. 

The treatment is the same as for the other acute forms of meningitis, 
with particular attention to nutrition. 



ACUTE EXTERNAL PACHYMENINGITIS 

This form, which is rare, is secondary to cranial bone disease and to 
suppurations of the middle ear and mastoid. It may be due to syphilis. 

The prognosis is good, if the pia or the sinuses are not involved, and if 
the treatment is proper. 

The treatment is surgical apart from antisyphilitic management. 



748 



THE NERVOUS SYSTEM 



CHRONIC INTERNAL PACHYMENINGITIS 

Synonyms: Hemorrhagic pachymeningitis; hsematoma of the dura 
mater. 

This disease is not common in general practice, but is not uncommon in 
insanity and degenerative diseases of the brain. Most of the subjects have 
been alcoholics, and it is almost exclusively found among tramps and alms- 
house inmates. There may be symptoms of slow or sudden compression. 
The prognosis should be guarded. 

SPINAL PACHYMENINGITIS 

Pachymeningitis Externa Spinalis 

This form may be acute or chronic. The acute form is due to an ex- 
tension of a neighboring abscess or of an inflammation of a vertebral bone. 
The chronic form is almost always tuberculous, and is an extension of a 
tuberculous process in a vertebra. 

Symptoms. — We observe irritation and compression of the anterior and 
posterior nerve roots of the cord, causing hyperesthesia, motor spasms, 
anaesthesia, paralysis, atrophy of muscles, and loss of reflexes. The later 
compression of the cord itself causes loss of motion and loss of sensation 
below the level of the lesion. 

The treatment is symptomatic or surgical with due regard to the 
underlying condition. 

Pachymeningitis Interna Hemorrhagica Spinalis 

The lesions of this disease of the spinal meninges are identical with 
those of the cerebral meninges in the same disease, and the two are usually 
associated. That portion of the meninges close to the cerebral meninges 
is usually affected. We find pain in the back and motor and sensory irrita- 
tion and impairment. Sudden exacerbations may occur from time to time, 
due to haemorrhages with compression. 

Treatment does no good. 

Pachymeningitis Interna Hypertrophica Spinalis 

Pathology. — The dura changes into a thick, fibrous tissue. This at first 
irritates the nerve roots, then destroys them, and compresses the cord. 
The process is usually found in the cervical region, and surrounds the cord 
like a ring. 

Symptoms. — During the stage of irritation of the anterior and posterior 
nerve roots, there are neuralgic pains along their course, referred to the neck, 
the arms, and the upper portion of the thorax. Hyperaesthesia, tingling, 
spasm, and rigidity also occur in these regions. During the stage of destruc- 
tion of the nerve roots and pressure on the cord, there are anaesthesia, 
paralysis, atrophy, and loss of reflexes. The location of these symptoms 
depends upon that of the lesion. 



SYPHILITIC EXUDATIONS INTO THE MENINGES 



749 



The prognosis, as to recovery, is bad, but death is usually due to some 
other disease. Occasionally the disease is arrested, and although there are 
deforming contractures, the patient may live for years. 

Treatment. — In addition to potassium iodide, we may employ counter- 
irritation and vibration to the diseased portion of the spine. 

SYPHILIS OF THE NERVOUS SYSTEM 

Nervous derangements due to syphilis often present a most serious 
aspect, but generally respond readily to specific treatment. The inflamma- 
tory process uusally begins in the blood vessels, and extends from there 
to the meninges and connective tissue structures of the brain and cord. 

Inflammatory syphilitic disease of the nervous system may be classed 
as cerebral, spinal, cerebrospinal, and syphilis of the peripheral nerves. 

Cerebral syphilis includes syphilitic endarteritis, syphilitic meningo- 
encephalitis, syphilitic deposits in the brain itself (gummata), and hereditary 
syphilis. 

SYPHILITIC ENDARTERITIS 

Syphilitic endarteritis is one of the simplest forms of brain syphilis. It 
results in anccmia and malnutrition of those parts nourished by the vessels 
involved or in thrombosis and hence softening. 

Symptoms. — We observe symptoms of neurasthenia, anaemia, etc., as 
we should from endarteritis due to other causes. The most characteristic 
symptoms, however, are temporary attacks of aphasia, paralysis, hemi- 
anopsia, weakness, double vision, vertigo, delirium, headache, etc. We 
think from such symptoms that an apoplexy is imminent, but the process 
seldom advances to this degree. 

The prognosis should be guarded, for if the process has gone on to 
thrombosis, the cure by antisyphilitic treatment is not complete. 

The treatment should be vigorous. Mercurial inunctions should be 
given to the point of salivation. They should be preceded by a hot bath 
and an alcohol sponge to remove all grease and aid absorption. Potassium 
iodide in large doses should be given, beginning with gtt. xx of a saturated 
solution and increasing up to xl t. i. d. In extreme cases 500 grains may 
be given in a day. 

SYPHILITIC TOXAEMIA 

In this form there may be the general symptoms of neurasthenia, with 
insomnia and headache. The latter is worse at night. In ordinary neuras- 
thenia the patient feels worse in the morning. In the cases due to a poison- 
ing with syphilis the patient feels worse at night. 

The treatment is as above stated. 

SYPHILITIC EXUDATIONS INTO THE MENINGES 

These exudations are likely to occur in the lowest portions of the cranial 
cavity or at places of least resistance, as at the base of the brain, at the 
crura, at the sides of the pons, or in the medulla. The disease may affect the 



750 



THE NERVOUS SYSTEM 



cranial nerves. It occurs in from one to two years after the chancre, or it 
may occur later. The exudation may gather in a short time, so that the 
symptoms may develop rapidly. 

The cortex may be covered by this exudate, creating localized spasms, 
hallucinations, and supersensitiveness to light (photophobia). These irri- 
tation symptoms may be followed by paralysis. There are also headache 
(which is worse at night), insomnia, irritability of temper, dulness (especially 
in the morning), restlessness, vertigo, fulness of the head, throbbing in the 
head, and vomiting, which is sometimes projectile and has no relation to the 
ingestion of food. 

As to the localization of the exudate, there may be involvements of the 
cranial nerves, especially the third, sixth, seventh, and eighth. The fifth 
is less frequently involved. There may be optic neuritis, aphasia, convul- 
sions, apoplexy, increased thirst and hunger from disturbance of the frontal 
lobes, polyuria, etc. The symptoms, in fact, may be those of a tumor of 
the brain, and we can distinguish them sometimes only by the greater 
rapidity of development of symptoms in syphilitic cases. Antisyphilitic 
treatment will surely show the difference. 

OTHER SYPHILITIC CONDITIONS 

Syphilitic Deposits in the Brain. — There may be small areas of softening 
or sclerosis — a diffuse syphilitic softening. The symptoms are those of 
general paresis. The diagnosis is impossible except by trying antisyphilitic 
treatment (therapeutic test). 

Gummata of the brain give rise to the same symptoms as tumors, and 
can be distinguished only by antisyphilitic treatment. 

Hereditary syphilis of the brain causes faulty development, cerebral 
atrophy, or cerebrospinal sclerosis. Look for other signs of syphilis. 

Spinal Syphilis. — There may be the same pathological changes here as in 
the cerebrum, such as gummata attached to the meninges, arteritis with 
secondary softening, meningitis with secondary cord changes, or sclerosis 
developing late in the disease. 

The symptoms are extremely varied. 

Cerebrospinal syphilis gives rise to the symptoms of both brain and cord 

disease. 

Syphilis of the Peripheral Nerves. — It is quite rare that syphilis attacks 
the peripheral nerves, but we occasionally see cases of nerve irritation and 
compression due to a syphilitic exudate. There is said to be a form of 
multiple neuritis produced by syphilis. In cerebral and spinal syphilis 
the nerve roots may be attacked, causing a radical neuritis. 

Treatment. — In general, as regards treatment, we should always try 
antisyphilitic drugs in the nervous diseases of obscure origin, as from time 
to time we are unable to get a history of a primary lesion. 



INJURIES TO THE BRAIN 



751 



MISCELLANEOUS LESIONS IN THE BRAIN AND SPINAL 
CORD, SUCH AS CONTUSION, LACERATION, CONCUSSION, 
COMPRESSION, HEMORRHAGE, TUMORS, CYSTS, ABSCESS, 
SINUS THROMBOSIS, AND PARASITES 

In this group of lesions we usually observe pressure symptoms, and 
localization is of practical importance on account of the possibility of sur- 
gical aid, which might be indicated except in syphilitic gummata. 

INJURIES TO THE BRAIN 

CONTUSION AND LACERATION 

By contusion and laceration of the brain an injury is meant which is 
severe enough to cause symptoms due to the contusion or laceration or to 
be followed by grave symptoms independent of those caused by concussion. 
The same injuries that occur in other parts of the body may occur here. 
In addition, peculiar injuries may take place, owing to the nature of the 
hard bony covering, the blood supply of the brain and cerebrospinal fluid, 
by contrecoup and by rupture without external manifestations. 

Symptoms. — We first observe those of concussion, and then, from ex- 
travasation of blood, those of compression; and again, there may be no symp- 
toms of compression. In laceration of the cortex, according to the location 
and degree of injury, there may be spasms or rigidity of the muscles whose 
centres are involved, with more or less paralysis. There may be no evidence 
of a laceration having taken place until after four or five days, or even 
later, when there may appear convulsions or rigidity of muscles. These 
later symptomatic manifestations are due to vascular changes, probably 
in the nature of a spreading oedema or posttraumatic haemorrhage. 

There may also appear, frequently within a few hours, mental symptoms 
supposed to be due to cerebral irritation. The patient lies on his side, 
curled up in bed, with the limbs flexed and the back curved forward. The 
eyelids are kept closed, and although sometimes the patient may be induced 
to use a bed pan, he usually exercises no control over the sphincters. The 
pupils are contracted and react to light. The pulse is slow and weak, and 
the temperature is normal or subnormal. But the most characteristic 
feature is an intense irritability of temper, a lack of control. The patient 
seems to wish to lie undisturbed, and if efforts are persistent to rouse him, 
he may get excited and use strong and even blasphemous and abusive 
language. It may be necessary to offer him food in order to have him take 
sufficient nourishment. These mental symptoms gradually disappear in 
from one to three weeks. The mind may be affected for some time afterward 
in some cases, and in some it is permanently affected. One may have no 
remembrance of this mental condition after recovery, or it may remain a 
hazy recollection. 

Diagnosis. — It is often impossible to ascertain the extent of contusion 
or laceration immediately after an injury. The advent of convulsions, 
rigidity, or paralysis of groups of muscles, from the second to the fifth day, 



752 



THE NERVOUS SYSTEM 



points strongly to contusion. It is stated that oedema of the optic nerve or 
of the retina is often present in these cases, but absent in pure concussion. 

Prognosis. — This depends principally upon the extent of the injury and 
upon the entrance of infection. (Edema or haemorrhage may take place 
and cause death from spreading, which it tends to do. If microorganisms 
lodge in the bruised brain tissue, death may result from acute encephalitis. 
Or the purulent process may remain localized and result in an abscess. The 
spreading oedema may cause a gradual necrosis (yellow softening), which is 
limited by the amount of vascular disturbance. 

Remote changes, such as the formation of a cyst from the lacerated tissue 
and extravasated blood, may take place. Scar tissue may result, irritating 
the adjacent tissue, and if situated in the motor area, may give rise to Jack- 
sonian epilepsy. 

If an extensive growth of fibrous tissue results at the seat of the injury 
(sclerosis) and spreads, it may disturb the brain functions. A descending 
degeneration takes place, extending down the pyramidal tracts into the 
spinal cord, in all cases where the cortex in the motor area is lacerated. 

Treatment. — As it may be several days before we can determine whether 
contusion or laceration has taken place, our treatment is largely expectant. 
The patient should be kept absolutely quiet, the head shaved, and ice bags 
or Leiter's coil applied. Should extravasated blood give signs of com- 
pression, trephining is indicated, and should abscess develop, we should aim 
to find its location and drain the pus cavity. 

MENINGEAL HEMORRHAGE 

Blood may accumulate between the dura mater and the skull or between 
the dura and pia mater. 

Hemorrhage between the Dura Mater and the Skull 

iEtioIogy. — This is generally due to injury, either from a fracture or from 
concussion which separates the dura from the bone and tears the middle 
meningeal artery. 

Symptoms. — We observe first those of shock, then those of compression, 
and then those of meningitis. 

The diagnosis is very important from a medicolegal standpoint (see 
chapter on Coma). 

The treatment is surgical. 

Haemorrhage between the Dura Mater and the Pia Mater 

./Etiology. — 1. Traumatism; 2. Thrombosis of the venous sinuses; 3. 
Chronic hemorrhagic pachymeningitis; 4. Rupture of an aneurysm of one 
of the cerebral arteries; 5. After convulsions in children; 6. Hemor- 
rhagic diseases. Under traumata are included the injuries to the new-born 
from pressure during delivery, as the result of severe labor or from forceps. 
We find the hemorrhage at different points, as at the base of the brain, at 
the convexity, or equally distributed. Cerebral hemorrhage may make its 



CONCUSSION OF THE BRAIN 



753 



way to the cortex or through the fourth ventricle, to appear between the 
membranes. 

Symptoms. — These differ according to the situation. If there is a large 
clot over one cortex, there are sudden coma, stertorous breathing, slow 
pulse, and abolition of all reflexes. The paralysis may be a hemiplegia or a 
monoplegia. The paralysis is preceded by twitching of the muscles, which 
later become paralyzed. At first the temperature falls, even to 96°, but 
later may rise to 105° or higher. The condition may improve and re- 
covery takes place if the clot is small. Otherwise the patient dies in coma 
or with symptoms of meningitis. If the clot is small, coma may be absent, 
but the symptoms of meningitis may develop. 

If there are clots over both hemispheres, there are sudden coma and 
general convulsions. The diagnosis may be difficult in these cases. 

If the clots form at the base of the brain, pressure of the medulla, the 
centre for the vital functions, may cause death in a few hours. Frequently 
the pressure here causes high temperature. 

In the new-born, after a difficult labor, the child may be born dead. It 
may be deeply asphyxiated and die soon, or recover to go into coma and 
convulsions and die in a few days. If it recovers, it may have paralyses, 
sometimes with athetosis, mental defects, and epilepsy. Cerebral atrophy 
ma) r occur. 

The prognosis is bad except in those cases where the clot is small. If 
the patient recovers, there may be paralysis and convulsive movements. 
In the fatal cases death usually ensues earlier than in cases of cerebral 
haemorrhage. 

CONCUSSION OF THE BRAIN 

By this term we mean the condition into which a person is thrown 
after a blow upon the head. This may result from one blow or a suc- 
cession of blows upon the head or from a blow transmitted through the 
vertebral column. 

Pathology. — There are only theories concerning the true pathological 
conditions. One is that there are multiple minute haemorrhages, or that 
the symptoms are due to a vascular disturbance, such as paralysis of brain 
capillaries with distention and pressure. 

Symptoms. — These vary according to the severity of the injury. The 
mild cases show merely a loss of consciousness for a few seconds, with arrest 
of respiration and pallor. Recovery is rapid. In case of severe injury, 
however, a person may die in a few minutes. The cases coming between 
these two extremes show the following symptoms: 

1. Stage op Collapse. — There is sudden loss of consciousness; the 
patient may be roused by shouting or pricking, or the unconsciousness may 
be complete; this may last from a few seconds to several days. The pulse 
is weak and, as a rule, slow. The skin is pale and cold. The respirations 
are slow, shallow, and sometimes irregular. There is a temporary muscular 
paralysis, although usually the patient will swallow fluid introduced into 
the mouth. Pinching or pricking the skin will arouse the .patient in all 
except the severe cases. In mild cases the reflexes are present, but in severe 
cases all are lost, even the corneal. The pupils are equal, more or less dilated, 



754 



THE NERVOUS SYSTEM 



and react to light except in grave cases. There may be loss of control of the 
sphincters from relaxation, not from paralysis. The temperature in the 
rectum is always subnormal, even down to 96° or 95° F. 

2. Stage of Reaction. — Vomiting is one of the first signs of return- 
ing consciousness. An epileptoid convulsion may take place. The pulse 
gradually becomes stronger, the skin warmer, and the respiration deeper 
and more regular. The temperature usually rises slightly, but seldom to 
over 100° F. As consciousness returns the patient usually complains of 
headache. He now rapidly becomes convalescent, unless compression or 
laceration exists, their symptoms usually showing in this stage. Occasion- 
ally, after reacting, the patient may become comatose and die. Death in 
these cases seems to be due to encephalitis or spreading cedema. 

3. Stage of Convalescence. — This may last from a few days to weeks 
or months, but if it lasts as long as weeks or months, the condition is prob- 
ably one of contusion or laceration. 

Diagnosis. — Under the subject of Compression of the Brain the differen- 
tial diagnosis will be discussed. 

The prognosis in uncomplicated cases is good, though posttraumatic 
dementia may develop. 

Treatment. — Make the body warm, and lower the head. The head 
should be shaved and carefully examined for injury. We must be careful 
about using alcohol or other strong stimulants, on account of danger of 
increasing the haemorrhage, if any of the vessels are ruptured, and also of 
causing hypersemia of the brain, which may lead to spreading cedema. 
Still, we had better give a stimulant if it is decidedly indicated. To in- 
crease the heart's activity, we may irritate the skin with a sinapism over 
the pit of the stomach, over the heart, and on the calves of the legs. If 
mustard is not at hand, hot water and a sponge may be used. We may 
subcutaneously administer a mixture of ether and camphorated oil, repeat- 
ing the dose according to the need. As the patient can swallow, we can 
give him large doses of musk by the mouth, which tends to improve a 
small and irregular pulse. A good stimulant is the electric brush applied 
over the palms of the hands and the soles of the feet. Brief inhalations 
of ether may be helpful. 

When the patient does not breathe, or when the respirations are super- 
ficial or irregular, we may resort to artificial respiration, keeping it up for 
a long time if necessary. 

If there are subsequent symptoms of cerebral congestion, apply an ice 
cap to the head, apply dry cups to the chest and back, administer a drastic 
cathartic, perform venesection and give morphine to quiet the patient if 
necessary. Lumbar puncture and trephining may be indicated when the 
symptoms of compression (unconsciousness and a small pulse) are urgent. 

COMPRESSION OF THE BRAIN 

There may be a general compression of the whole central nervous system 
caused by an increased pressure of the cerebrospinal fluid, a localized pres- 
sure directly on some part of the central nervous system. 

Etiology. — The causes include those that are traumatic, such as depressed 
fracture, collections of pus, serum, or lymph, a foreign body, and effused 



COMPRESSION OF THE BRAIN 



755 



blood; and tumors, such as gummata, carcinomata, sarcomata, gliomata, 
osteomata, angeiomata, and tuberculous growths. 

Symptoms. — Usually the compression sets in gradually, and, no matter 
to what it is due or where it is located, we observe these general symptoms: 

Consciousness. — At first there is headache, which increases gradually, 
with drowsiness. This drowsiness becomes insensibility of a greater or less 
degree, and finally coma, which varies in intensity according to the degree 
of compression. 

Circulatory System. — A slow, full, heaving pulse is characteristic, 
but if the compression is severe, the pulse becomes rapid and irregular. 

Respiratory System. — Moderate compression causes regular, slow, 
and deep respirations, but in severe compression we find them rapid and ir- 
regular, almost approaching the Cheyne-Stokes type. When death occurs, 
the respirations stop first, and the pulse may continue for hours, sometimes, 
if artificial respiration is performed. 

Motor System. — Convulsions are present if the intracranial pressure 
is raised rapidly, but, as the pressure is usually gradual in development, they 
are rare. The voluntary muscles are usually progressively paralyzed. 
Hemiplegia is generally present for a time, as the paralysis begins, but 
gradually the other side also becomes paralyzed. Now the respirations 
become stertorous, and the lips and cheeks are blown out, showing that the 
muscles of the soft palate, the lips, and cheeks have become affected. Both 
sides of the body may be affected equally if the pressure in the brain is 
equally distributed, or a single group of muscles if the compressing agent is 
small and localized. 

Sensory System. — The patient may respond to skin irritation early 
in the compression, but later all sensibility is gone. 

The reflexes gradually disappear. 

Pupils. — If the cerebral pressure is equally distributed, the pupils are 
equal, at first contracted, then dilated and immobile. If the point of 
pressure occurs on one side first, which is usual, the pupil on that side 
contracts first and then dilates, while the other remains normal. As the 
pressure increases, however, the other pupil goes through the changes, until 
both are widely dilated and immobile. 

Choked Disc. — The sheath of the optic nerve being formed by the dura 
and arachnoid of the brain, increased pressure of the cerebrospinal fluid 
causes pressure on the optic nerve. Blood may also be pressed along the 
sheath, or there may be direct pressure against the nerve. Swelling of the 
nerve and resulting oedema cause the swelling of the optic disc on the retina, 
choked disc, which is a diagnostic point in brain compression. 

The sphincters are paralyzed, although the rectum is not. The bladder 
is paralyzed, and we observe retention and then a dribbling overflow. 

The temperature is at first subnormal, but it rises with the increase 
of pressure, so that in some fatal cases there is very high fever. The side 
of the body opposite to the lesion, if it is limited to one side, may be slightly 
warmer than the other. 

Diagnosis. — From the fact that both concussion and compression of the 
brain are due to injury, there is often great difficulty, at first, in distinguishing 
between the two. We cannot lay much stress upon the pulse or upon the 



756 



THE NERVOUS SYSTEM 



unconsciousness. The condition of the muscular system, however, enables us 
to make the distinction. In concussion the muscles are more or less flaccid, 
and are not moved voluntarily until consciousness returns. Then, however, 
they can be moved, showing the paralysis to be only functional. In com- 
pression, however, the paralysis is complete, and even if consciousness 
returned, paralysis would remain. The loss of muscular tone is greater in 
compression, as is shown by the stertor and blowing out of the cheeks 
during expiration. Muscular paralysis can be recognized easily in the early 
stage of compression by comparing the two sides of the body. There is a 
difference in the tonicity, which may be especially noticed in the face 
muscles. ■ 

The effect of concussion on the bladder and rectum is different from that 
of compression. In both cases the sphincters are relaxed, but there is no 
marked paralysis in concussion. 

The pupils in concussion are either not at all affected or else more or less 
dilated equally on both sides. They react to light except in cases of very 
severe concussion. In compression they are unequal while the compression 
is advancing, and in the final stage they are equal, are widely dilated, and 
do not react to light. Choked disc is usually present in compression after 
forty-eight hours. 

In regard to the state of coma, there are other conditions inducing it, 
and they must be distinguished. During the course of some diseases, such 
as epilepsy, meningitis, tumors of the brain, renal disease (uraemia), diabetes, 
etc., coma may arise. Injuries to the head, alcoholic and narcotic poisoning, 
cerebral haemorrhage, embolism and thrombosis, heat stroke and exposure 
to cold may all induce coma. For the distinction, see table in the chapter 
on Coma. 

To make a diagnosis at a moment's notice is often impossible, and we 
should never decide at once, but keep the patient in bed under observation 
for at least forty-eight hours. 

Localizing Symptoms. — The pressure at certain points in the brain may 
give rise to symptoms which would tell us the location of these points. 
(See Brain Abscess and Brain Tumor.) We should notice, therefore, any 
difference between the two sides of the body in the musculature and 
temperature, and any difference in the pupils. 

Prognosis. — If the compression is not removed, the symptoms grow 
worse usually and death results. Sometimes the pressure is relieved 
spontaneously, and sometimes the brain becomes accustomed to it, and 
recovery gradually takes place. If the point of pressure is at a place which 
can be reached by operation, and the cause is removed, particularly in 
depressed fractures and blood clots, and the removal is effected early, the 
prognosis is good. 

Treatment. — Surgical methods are the only resource. The operation 
should be done early, preferably in the first stages, where the symptoms are 
those of irritation, and before the changes in the retina have advanced 
further than venous congestion. If pressure is allowed to continue for any 
length of time, the brain is likely to undergo atrophy or softening, or calcify 
in patches, resulting in damage which Nature cannot heal. 



TUMORS OF THE BRAIN 



757 



TUMORS OF THE BRAIN 

In order of frequency, we find gummata, tuberculous tumors, gliomata, 
sarcomata, carcinomata, occasionally fibromata, osteomata, cholesteato- 
mata, angeiomata, lipomata, and echinoccus and cysticercus cysts and other 
cysts. Aneurysms of the base of the brain may give rise to symptoms of 
tumor. 

The gummata usually begin in the meninges, may be found on the base 
or cortex, and are hard or soft. 

The tuberculous growths may be found anywhere. They may be pri- 
mary, but are usually secondary. They are hard, often multiple, and are 
more frequent in children, more than one half of the brain tumors in 
children being tuberculous. 

Gliomata are usually situated in the white substance. These tumors re- 
semble the nerve tissue, being composed of cells and fibres like the neuroglia. 
They grow singly, usually in an infiltrating manner, without capsule or 
boundaries, but often are vascular, making the symptoms vary. Haemor- 
rhage may take place. Sometimes the growths are hard. They are often 
combined in a sarcomatous growth. 

Sarcomata usually develop from the connective tissue of the membranes, 
but they may arise in the brain or from the bones. We find all varieties, 
fibrosarcoma, round celled and spindle celled sarcomata, gliosarcomata, and 
myxosarcomata. They are hard, single, well defined, easily separated, of 
various sizes, and may be found on the base, in the meninges, and in the 
cerebellum. 

Carcinomata are rare and usually secondary. Cancer or sarcoma begin- 
ning in the meninges may invade the bones and appear externally, forming 
the "fungus haematodes" or "perforating tumor of the dura." 

^Etiology. — Age: Children, being most liable to tuberculous growths, 
are oftenest affected. Young adults are next liable, and tumors seldom 
occur in the brains of old people, except carcinomata. 

The exciting causes are usually unknown. 

Pathology. — According to Starr, the tumors are in the cortex in 25 per 
cent of cases, in the cerebellum in 25 per cent, in the centrum ovale in 15 per 
cent, in the basal ganglia in 10 per cent, in the pons in 10 per cent, and in the 
crus and corpora quadrigemina in 10 per cent. Other situations show the 
tumor in about 5 pe • cen 

The brain tissue in the vicinity of a tumor may be hypersemic and in- 
flamed or softened and destroyed. If the growth involves the pia mater, 
there will be localized chronic meningitis. Pressure on a venous sinus may 
cause hydrocephalus. There are other vascular disturbances. The cranial 
bones may be thinned out and the sutures and fontanelles separated. 

Symptoms. — These are divided into two groups. The first group com- 
prises the general symptoms of irritation and compression irrespective of the 
situation of the tumor; the second, those symptoms dependent upon the 
locality of the tumor. 

General Symptoms. — Headache occurs in 95 per cent of all cases. It 
is dull, deep, and stupefying as a rule, constant or remittent, general or 
local, and is likely to be intensified by any factor disturbing the circulation 



758 



THE NERVOUS SYSTEM 



in the brain. There may be local tenderness, shown by percussion of the 
cranium, and even in stupor or sleep the patient may be seen to have pain. 
The severity of the pain may be excruciating, and it is often worse at night, 
especially when the tumor is syphilitic. The patient may have the sensa- 
tion of a band about the head. In every case of persistent headache the 
patient should receive an ophthalmoscopic examination. 

Mental disturbances occur in 85 per cent of all cases. The patient 
becomes dull, apathetic, and inattentive; the memory becomes affected; 
depression is present; and childishness and an emotional condition, even to 
dementia and insanity, may develop. The speech is slow, fainting attacks 
occur, and finally there are stupor and coma. Hysterical symptoms should 
make one think of brain tumor. 

Optic neuritis occurs in 80 per cent of the cases, and is usually bilateral. 
The vision may not be affected for some time, but an ophthalmoscopic 
examination will show on the fundus venous congestion, swelling of the 
papilla, loss of the disc outline, haemorrhages, and a radiating appearance 
about the disc. Later, as vision fails, we observe atrophy of the optic nerve, 
which causes the disc to appear gray or white. The optic nerve changes 
may be absent in cases of small subcortical tumors. With the progressive 
advancement of the optic nerve atrophy, impairment of vision, narrowing 
of the visual field, and even blindness may result. 

Vomiting occurs in about 50 per cent of the cases, and is more frequent in 
tumors of the posterior fossa. It is "purposeless," having no relation to 
stomach conditions, and is often projectile in character. 

Vertigo is present in about 75 per cent of the cases. It is most constant 
and severe in tumors of the cerebellum, but may occur with tumors any- 
where upon a change in the position of the patient. It may be present even 
when the patient is lying in bed. 

General epileptoid convulsions {petit mal or grand mal) may be present, 
particularly in cerebral tumors. 

The pidse is usually slow, averaging between 50 and 60. 

Nystagmus, a lateral oscillation of the eyes, is frequently present, but 
more particularly with disease of the corpora quadrigemina and cerebellum. 

Loss of control over the sphincters is especially present when the tumor 
is involving the frontal lobes. 

Glycosuria and polyuria may be symptoms, particularly when the tumor 
is in the posterior fossa. The bowels are usually constipated. 

Localizing symptoms depend upon the position of the tumor. 

Frontal lobes. A tumor situated in this region causes mental dulness, 
lack of control over the emotions, irritability, inattention, childishness, or 
dementia. There may be loss of the sense of smell. If the third left frontal 
convolution is involved, there is motor aphasia. 

The central convolutions and the motor tracts. A tumor here may cause 
monospasm (Jacksonian epilepsy), which may be preceded by a sensory 
aura. Monoplegia may follow. These two symptoms indicate that the 
tumor is near the cortex. When it is deep, or in the capsule, we observe 
hemispasm and hemiplegia. Slight anaesthesia may be present in the 
paralyzed part. 

The occipital lobe and the visual tract. There is hemianopsia, which is 



TUMORS OF THE BRAIN 



759 



spoken of by the patient as half-blindness. We also note flashes of light on 
one side and hallucinations of vision. 

Left temporal lobe, first and second convolutions. A tumor here gives 
rise to sensory aphasia (word deafness). 

Left lower parietal lobe and angular gyrus or occipitotemporal tract 
involvement gives rise to sensory aphasia (word blindness) . 

At the base of the brain a tumor causes symptoms according to its 
situation. 

In the anterior fossa it may cause loss of the sense of smell. 

In the middle fossa it occasions hemianopsia and paralysis of the ocular 
muscles through the third, fourth, and sixth cranial nerves; neuralgia of the 
face and anaesthesia, by involvement of the fifth nerve; opposite hemi- 
plegia, neuroparalytic ophthalmia, nystagmus, bilateral spastic paralysis, 
and deafness. 

In the posterior fossa it may cause paralysis of the seventh, ninth, tenth, 
eleventh, and twelfth nerves; vertigo and ear symptoms; and cerebellar 
ataxia, a tendency to incline or fall to one side. 

The medulla, if involved, may cause widespread paralysis, either paralysis 
of the cranial nerves alone or hemiplegia with convulsions. 

Involvement of the cerebellum causes vertigo, vomiting, headache (which 
may be frontal or occipital), and early optic neuritis. If the middle lobe 
is involved, we observe the peculiar cerebellar ataxia and a pitching or reel- 
ing gait. 

Differential Diagnosis. — We determine the existence of a brain tumor 
from the general symptoms alone, or the local symptoms alone, or both 
the general and local symptoms. We have to distinguish tumors from 
chronic nephritis by examining the urine and noting the condition of the 
heart, arteries, and blood pressure; by an examination of the fundus of 
the eye; by the character of the headache, which is more severe in tumors; 
and by the age of the patient. Tumor is more frequent in young persons. 
There are no local spasms in ur&mia. By means of an eye examination, 
prescribing glasses, and counteracting anaemia by medication, we can 
exclude hypermetropia and astigmatism. The headache is not severe in 
these cases. By studying the patient, and by the condition of the optic 
disc, we may exclude hysteria. 

Abscess of the brain usually involves a history of injury or otitis 
media. There is often fever, the early symptoms are severe, and optic 
neuritis is rare. 

The situation of the tumor is indicated by the study of the symptoms. 
The " signal symptom " is a term applied to a beginning spasm or paralysis, 
such as numbness and twitching of the thumb, which gradually extends to 
the hand and then the arm. The order of appearance of the local symp- 
toms is an aid, such as first thumb, then hand, arm, and face. Then we 
may compare the local symptoms, such as paralysis with aphasia and 
paralysis with hemianopsia. 

The variety of tumor can sometimes be determined. According to the 
age of the patient and the rapidity of growth, we may surmise the nature 
of the growth. The history may help in syphilis, tuberculosis, cancer, or 
sarcoma. The rapidity of the onset may guide us, as tubercle and cancer 
49 



760 



THE NERVOUS SYSTEM 



advance rapidly. The signs of irritation are more frequent in glioma and 
meningeal tumors. The degree of variety in symptoms may guide us; 
there is more variation in the symptoms caused by glioma. Gummata, 
tubercles, and sarcomata are more likely to involve the base of the brain. 
Intracerebral tumors are often gliomata or sarcomata. Sarcomata of the 
pituitary body or aneurysm may cause early optic neuritis or a peculiar 
form of hemiopia. 

Course. — Usually we see general symptoms, but there may be first a 
local spasm or a general convulsion, with a " signal symptom." The number 
and severity of the symptoms gradually increase, and finally death occurs in 
stupor, in general convulsions, or suddenly from heart failure. Recovery 
may take place after specific treatment or from an operation if the tumor 
is accessible. 

The duration is from one to three years. 

The prognosis is bad, except where syphilis is the cause, and where the 
situation permits of removal. 

Treatment. — To exclude gumma, give inunctions of mercury, with potas- 
sium iodide up to 300 grains or more daily. Tuberculous tumors have been 
reported to have undergone encapsulation and calcareous change in con- 
sequence of appropriate tonic treatment. 

Surgical treatment is effectual when the tumor has caused the symptoms 
leading to its exact localization. Unfortunately, less than 5 per cent (Dana) 
are "operable." An exploratory trephining is many times indicated when 
doubt exists. There is likelihood of a return after removal. 

THROMBOSIS OF THE VENOUS SINUSES 

^Etiology. — Primary or marantic thrombosis may take place in cachectic 
patients or in the aged, and cause death. Exhausting diarrhoea in children 
under six months may rarely lead to thrombosis. 

Secondary septic thrombosis occurs as a complication of inflammatory 
conditions of contiguous parts or disease of the middle ear, fracture, or 
suppurative conditions outside the skull, particularly erysipelas, carbuncle, 
and parotitis. These cases are much more frequent than the primary 
cases. Secondary non-septic thrombosis may complicate embolism or pres- 
sure on a sinus by cerebral tumors. 

Pathology. — The obstruction to the circulation of that part of the brain 
affected by the lodgement of the clot in a sinus results in intense congestion 
and cedema of that part. Softening of this area of brain tissue may ulti- 
mately take place. The septic thrombi soften,* disintegrate, and may give 
rise to purulent meningitis and embolic abscesses, which often take place 
in the lungs. 

Symptoms. — For general cerebral symptoms, there are usually apathy, 
stupor, delirium, convulsions, muscular rigidity, vomiting, optic neuritis, 
and coma. It is seldom that localizing cerebral symptoms occur, and the 
condition is found only at autopsies, sometimes, where no exciting symptoms 
had existed. The involvement of the superior longitudinal sinus gives 
rise to the most marked cerebral symptoms, although they are never char- 
acteristic. The symptoms of the most diagnostic importance are cedema 



ABSCESS OF THE BRAIN (SUPPURATIVE ENCEPHALITIS) 761 



and distention of the veins outside the skull, in the parts where the veins 
pass through the bones to join the internal sinuses. If the superior longi- 
tudinal sinus is thrombosed, we observe congestion and cedema of the sides 
of the head and forehead, prominence of the anterior fontanelle in children, 
and epistaxis. Thrombosis of the cavernous sinus causes cedema and con- 
gestion of the eyelid and prominence of the eyeball. Thrombosis of the lat- 
eral sinus causes cedema and congestion over the mastoid. 

If we have to deal with a septic thrombosis, we observe chills, intermittent 
or remittent pyrexia, and the typhoid state. Meningitis and abscess of the 
brain, as complications, will give rise to their symptoms. 

The duration of the disease is from a few days to several weeks. 

The prognosis is bad, unless the thrombus is small and non-septic. 

Treatment. — Potassium iodide and calomel have been recommended for 
the cachectic form. Operative treatment has given some brilliant results. 

ABSCESS OF THE BRAIN (SUPPURATIVE ENCEPHALITIS) 

^Etiology. — 1. It occurs from continuity through the cranial bones. In 
about 35 per cent of cases abscess arises from injury to the scalp or skull; 
in about 10 per cent from caries of the cranial bones; in about 40 per cent 
from diseases of the middle ear; and in about 10 per cent from chronic sup- 
purative rhinitis. There is often an associated meningitis. 

2. Through the blood vessels. During the course of pyaemia, malignant 
endocarditis, gangrene or suppuration of the lung, empyema, or an infectious 
disease, septic emboli may lodge in the brain. 

Pathology. — The abscess results from an acute encephalitis with the 
formation of pus. The collection of pus may not be encapsulated, and then 
it extends rapidly with fatal results. Or it may be encapsulated and develop 
slowly. Sometimes it may remain stationary for a number of years, causing 
no symptoms, but ultimately enlarge or break. Multiple abscesses may 
form, secondary to pyaemia, which add cerebral symptoms to those of the 
pyaemia. The abscess may break through into a ventricle or through the 
cortex, causing meningitis. The course of abscesses of the brain may be 
acute or chronic. 

Symptoms in Acute Cases. — 1. Symptoms of Pressure. — There is 
headache, severe, constant, possibly localized; then follow vomiting of a 
cerebral nature, usually optic neuritis, generally irregularity of the pupils, 
slowness of the pulse, 60 to 70, alternating drowsiness, restlessness, and 
delirium, and finally coma. 

2. Symptoms Due to Pyaemia. — There is a chill with the onset, often 
repeated during the disease. There is irregular fever, but as a rule we see 
periods of normal or subnormal temperature. The typhoid condition finally 
supervenes. 

3. Localizing Symptoms. — Irritation or destruction of some portions 
of the brain, as in brain tumors, gives rise to special symptoms. Convulsions 
may be confined to certain groups of muscles. There is paralyses, hemiplegic 
or monoplegia, also aphasia. Phlebitis causes cedema behind the ear and a 
sensation of fulness over the jugular vein. Meningitis causes rigidity of the 
neck and cranial nerve paralysis. If the abscess is located in the frontal 



762 



THE NERVOUS SYSTEM 



lobes, it is usually caused by disease of the nose or ethmoid cells. Mental 
dulness may be the only symptom. In the temporosphenoidal lobe an ab- 
scess may cause no symptoms; if it is in the parietooccipital lobe hemian- 
opia may result. Vomiting, vertigo, and a staggering gait usually accom- 
pany a cerebellar abscess. 

A chronic abscess, developing in a part of the brain not specialized 
("silent region"), may become encapsulated without causing symptoms. 
The patient may be subject to headache and vertigo. Sooner or later the 
abscess ruptures into a ventricle or on to the cortex, and sudden coma or 
convulsions ensue. 

The diagnosis is made from the history, showing a cause of infection; 
from septic symptoms; and from localizing symptoms. 

DIFFERENTIAL DIAGNOSIS (STARR) 



Abscess 

Temperature normal or not high. 
Pulse slow. 
Patient in stupor. 
Spasms and rigidity rare. 
Cranial nerves not involved. 
Optic neuritis frequent. 

Abscess 

Temperature normal or not high. 
Pulse slow. 

Chill at the onset, not repeated. 

Little sweating. 

Head tender to percussion. 

No thrombi. 

No cedema. 



Meningitis 

Temperature high without remission. 
Pulse rapid. 

Irritable, all the senses overacute. 

Frequent. 

Involved early. 

Rare. 

Thrombosis of Lateral Sinus 

High with remissions. 

Rapid, weak. 

Frequently repeated. 

Profuse sweating. 

Pain over the mastoid and jugular. 

Thrombi in the lungs. 

More or less general cedema. 



The prognosis is grave unless the pus can be evacuated. 

In non-purulent haemorrhagic encephalitis following grippe, pneumonia, 
malarial disease, and typhoid fever the prognosis is not bad. 

The treatment is surgical. With improved knowledge in diagnosis, in 
the treatment of middle ear and sinus suppurations, and in surgical tech- 
nique, the mortality is decreasing. 

PARASITES OF THE BRAIN 

These are very rare in this country, but we occasionally find tumors 
due to the echinococcus and the Cysticercus celhdosce. The former produces 
hydatid cysts, such as are found in the liver. These cysts may be large or 
small, few or many, and are almost always on the surface of the brain. 

The cysticerci also form cysts, usually on the surface or in the ventricles, 
commonly multiple and generally encapsulated. As a rule, they give rise 
to no symptoms, but there may be persistent headache, convulsions (limited 



INJURIES OF THE SPINAL CORD 



763 



or general), and gradually developing blindness — the same symptoms as 
those of tumors. 

The treatment is surgical. 

INJURIES OF THE SPINAL CORD 

Concussion.— Under this head we usually speak of such slight lesions as 
very small lacerations, haemorrhages, or contusions. It has been described 
under Railway Spine. 

Laceration and contusion of the spinal cord may be extensive. They are 
usually associated with severe fractures or dislocations of the vertebral 
column. There is paralysis, which corresponds to the portion of the cord 
injured. It is possible for a complete, although slow, recovery to take place. 

Compression of the cord, either from a displaced bone, blood clot, or 
foreign body, such as a bullet, may take place. A blood clot from a haemor- 
rhage into the meninges or cord gives rise to intense pain in the back, 
hyperaesthesia, muscular spasm, rigidity, the sensation as if a cord were 
tied around the waist, and rapidly developing paralysis. 

Compression due to bone causes symptoms immediately after the injury. 
These symptoms are likely to be more serious, and although the bone may 
be removed, the damage may be permanent. 

Wounds of the Spinal Cord. — There may be a complete division of the 
cord by fractured or dislocated bones, by a knife, or by gunshot or other 
injury. There may be an escape of the cerebrospinal fluid. We may 
observe clear symptoms, indicating the situation of the injury. Sometimes, 
however, a less severe injury will cause symptoms of complete division of 
the cord. These may be due to the haemorrhage and oedema. More often 
there is a considerable portion of the cord injured, and the symptoms are 
extensive and not well defined. Cysts and abscess may form. Sepsis is not 
the rule. The paralysis is usually permanent. 

The treatment is surgical or symptomatic. 

Tumors, cysts, abscess, and parasites of the spinal cord cause symptoms 
of irritation and compression which point to the affected locality. 
The treatment is symptomatic, antisyphilitic, or surgical. 

HEMORRHAGE INTO THE SPINAL MEMBRANES 

Synonyms: Extramedullary haemorrhage, spinal apoplexy. 

^Etiology. — This is a rare condition. It may be caused by blows and 
concussions; chronic pachymeningitis haemorrhagica; rupture of an aortic 
aneurysm into the spinal canal after erosion of the vertebral bones ; rupture 
of an aneurysm of the vertebral or basilar artery; haemorrhagic diseases, 
such as purpura haemorrhagica and scurvy; and convulsions or tetanus; 
or it may be a lesion in caisson disease. Blood from the cranium may make 
its way downward between the membranes. 

Pathology. — The haemorrhage may be extrameningeal, between the bones 
and the dura, or intrameningeal, between the membranes. It is most fre- 
quent in the cervical region. It is quite rare for a sufficient amount of blood 
to escape to compress the cord. 



764 



THE NERVOUS SYSTEM 



Symptoms and Diagnosis. — We observe suddenly the symptoms of 
spinal irritation without fever. These are pain, radiating along the course 
of the nerves, muscular rigidity and spasm, and later some motor and 
sensory paralysis, although never to any great degree. The situation 
of the haemorrhage determines the nature and seat of the symptoms. If the 
cord is compressed, there may be a resulting myelitis. Spinal puncture 
may aid in diagnosis. 

The prognosis is not good. Perfect recovery, however, is seen after 
slight haemorrhages. The prognosis is better in extramedullary than in 
intramedullary haemorrhage. 

Treatment. — Apply ice bags to the spine while the patient is prone. 
Ergot is indicated in full doses early in the disease. Later, when there is 
no more bleeding, we treat as for myelitis. 

Surgical treatment may be indicated. 

REMARKS ON THE SYMPATHETIC NERVOUS SYSTEM 

There is much about the physiology and pathology of the sympathetic 
nerves which is not known. We know that the sympathetic system con- 
sists of a chain of ganglia along either side of the spine, united by inter- 
vening and some transverse branches; that the ultimate distribution of 
all terminal branches seems to be in connection with the small vessels; that 
there are subdivisions into plexuses — the cervical portion with the cavernous 
plexus and carotid plexus, the great solar plexus, the thoracic branches with 
the great splanchnic nerve, the pelvic plexus, and numerous smaller plexuses. 

The functions seem to be varied, but probably this system has largely 
for its office the control of the blood supply in the various organs and parts 
of the body. Indirectly it probably is concerned in the secretion of sweat 
and the function of various glands. In particular, the cervical sympathetic 
controls the dilatation of the pupil; it supplies motor fibres to the unstriped 
muscular fibres of the orbit; it controls the action of the salivary glands and 
sweat glands of the face and neck. It also sends vasomotor branches to the 
ear, the side of the face, the conjunctiva, and the eye, throat, brain, and its 
membranes. 

In the thorax, the sympathetic nerves supply accelerator fibres to the 
heart. The great splanchnic nerve takes its origin from the sympathetic 
system. 

In the abdomen and pelvis, it is associated with the motor and vasomotor 
supply of the large intestine, bladder, uterus, vas deferens, and vesiculse 
seminales. The branches of the sympathetic are very numerous in the 
suprarenal capsules, having connections with the renal and solar plexuses. 

Pathology. — In regard to the morbid changes in this system very little 
is known, and much that is written is conjectural and hypothetical. 

The cervical portion, being the most superficial, may suffer from pene- 
trating, incised, and gunshot wounds, blows, contusions, and pressure from 
such tumors as aneurysms, enlarged glands, exostoses, and malignant 
growths. It may be irritated by affections at the apices of the lungs and 
of the contiguous pleura. The acute infectious processes seldom may in- 
volve it. Cerebral lesions may involve this portion, and its irritation has 



ABNORMITIES OF THE BRAIN 



765 



been noted in some cases of hemiplegia. Hyperidrosis has been described 
when a pathological condition existed in the seventh nerve, also symptoms 
of paralysis of the cervical sympathetic with incomplete closure of the 
palpebral cleft. The part of the brain connected with the cervical sym- 
pathetic is supposed to be the optic thalamus. 

Hyperidrosis, dilatation of the pupil, and widening of the opening of 
the lids are symptoms of cervical sympathetic irritation. If there is paraly- 
sis, we observe opposite symptoms, such as a contracted pupil, sometimes 
associated with a slow reaction to light ; narrowing of the opening between 
the lids; in old cases retraction of the bulbus oculi; occasionally increased 
redness and warmth in the ear and cheeks ; and in a few cases an increased 
secretion of sweat. In both cases there are sometimes slight trophic dis- 
turbances in the cheeks. In some cases of complicated paralyses of the 
brachial plexus, which are usually traumatic, symptoms of paralysis of the 
sympathetic have been observed, such as contraction of the pupil, narrow- 
ing of the opening between the lids, and retraction of the eyeball on the 
paralyzed side. This is probably due to a lesion of the branch of the sym- 
pathetic communicating with the first dorsal nerve. Vasomotor symptoms 
in the face are usually missing, although a peculiar flattening of the cheeks 
has been observed. 

There are theories that the sympathetic is pathologically involved in 
cases of goitre. Migraine has been supposed to be due to an affection of 
the sympathetic. Irritation in the area of the splanchnic nerve in the 
abdomen in lead poisoning is supposed to be the cause of the colic and the 
constipation. 

ANATOMICAL ANOMALIES 

ABNORMITIES OF THE BRAIN 

The term anencephaly is applied to those cases where the brain is absent 
or rudimentary. The cerebellum and part of the basal ganglia may be 
present, making it possible for the child to live a short time. 

Cyclopia is a malformation in which the orbits form a single continuous 
cavity. It is also called synophthalmia. 

Acrania is an entire absence of the bones and integuments forming the 
vault of the skull. It is usually associated with anencephaly. 

Meningocele and meningoencephalocele are hernia of the brain mem- 
branes, arachnoid, and dura through a cleft in the skull. When the brain 
also protrudes, it is called encephalocele. These usually occur in the median 
line of the occipital region. When there is a hernial sac with fluid con- 
tents, it is called hyalr ■encephalocele. 

Porencephaly. — A congenital defect in the nutrition of the brain leads 
to a cavity or depression in the cerebral hemispheres which reaches generally 
into the lateral ventricle. It is probably due to some intrauterine accident 
causing aneemia and softening, haemorrhage, or thrombosis. It is one of the 
causes of cerebral palsies in children. 

Microgyri and atrophies of the cortex are observed. 



766 



THE NERVOUS SYSTEM 



MALFORMATIONS OF THE SPINAL CORD 

Spina Bifida (Rhachischisis Posterior) 

This is the name given to a congenital hernia of the membranes of the 
cord, and sometimes of the cord, through a cleft in the vertebrae, due to 
absence of the vertebral arches. 

iEtioIogy. — Hereditary influence is sometimes considered a factor. It 
is not rare, and is often associated with hydrocephalus or some other develop- 
mental defect, such as imperforated anus, ventral hernia, etc. 

Forms. — Spinal meningocele is the form where only the membrane 
protrudes into the hernial sac. 

In spinal meningomyelocele the membranes and cord both protrude. 

Meningomyelocele (hydrorrhachis interna) is a form in which the 
inner lining of the sac is formed by the thinned out spinal cord with disten- 
tion of the central canal of the cord. 

The first two forms are the more common, and are called hydrorrhachis 
externa. The subarachnoid sac is the inner wall of the cyst. In two thirds 
of the cases both the nerves and the cord protrude into the sac, but in 
some of these only a few nerves are found. When these structures are present 
in the sac, they lie on the posterior median surface. These tumors contain 
cerebrospinal fluid and sometimes connective tissue and fat. 

Spina bifida is usually seen in the lumbar region, and seldom more than 
two or three vertebra? are involved. We see a difference in the size of the 
tumors, as they may vary from 3 to 15 cm. in diameter. The base may be 
sessile or pedunculated. The outer skin may be glossy, tough, thickened, 
or ulcerated. 

Symptoms. — Feebleness, poor nutrition, and mental feebleness are 
usually seen in these children. One half of the cases are paraplegic, and 
sometimes there is involvement of the sphincters and anaesthesia. Not 
infrequently we see talipes. 

Prognosis. — Without treatment the cases are usually hopeless, and 
even with treatment they are grave. Spontaneous closure is occasionally 
observed. 

Diagnosis. — We have to distinguish spina bifida from congenital tumors 
in the region of the lower vertebrae. If there is much anaesthesia, paraplegia, 
and sphincter trouble, we may conclude that the cord is in the sac, which 
is very important to know. To be positive, we may introduce an insulated 
needle connected with a battery with a view of eliciting peripheral symp- 
toms. 

The treatment is surgical, but it is best to withhold operations until the 
child is at least three months old. (See also Paediatrics.) 

OTHER MALFORMATIONS 

Amyelia. — Absence of the spinal cord does not exist unless the brain is 
absent. The spinal nerves are usually present in amyelia. In such cases 
the patients cannot live. 

Double cord is a very rare condition. Unless there is a double canal, 
the defect exists in only a part of the vertebral canal. 



REMARKS ON IDIOCY AND AMAUROTIC FAMILY IDIOCY 767 



A double central canal involving only a part of the cord is not rare. 

Asymmetry of the cord is not particularly rare. It is commonly due 
to an abnormity in the pyramidal tracts. 

Splitting of the cord is occasionally seen, as well as defects at various 
levels. 

Micromyely is not very rare. 

STIGMATA OF DEGENERATION (PETERSON) 

Anatomical Stigmata. — Cranial Anomalies. — Facial asymmetry; de- 
formities of the palate; anomalies of the teeth, tongue, lips, or nose. 

Anomalies of the Eye. — These are flecks on the iris, strabismus, chromatic 
asymmetry of the iris, narrow palpebral fissure, albinism, congenital cataract, 
and pigmentary retinitis. 

Anomalies of the Ear. — Visible malformations. 

Anomalies of the Limbs include polydactylism, syndactylism, ectro- 
dactylism, phocomelus, and excessive length of the arms. 

Anomalies of the Trunk are herniae, malformation of the breasts and 
thorax, dwarfishness, gigantism, infantilism, femininism, masculinism, and 
spina bifida. 

Anomalies of the Genital Organs. — Visible malformations. 

Anomalies of the Skin include polysarcia, hypertrichosis, absence of 
hair, and premature grayness. 

Physiological Stigmata. — Anomalies of Motor Function. — Walking late; 
tics; tremors; nystagmus; epilepsy. 

Anomalies of Sensory Function. — Deaf-mutism; neuralgia; migraine; 
hyperesthesia; anaesthesia; blindness; myopia; hypermetropia; astigmatism; 
hemeralopia; concentric limitation of the visual field. 

Anomalies of Speech. — Mutism ; defective speech ; stuttering ; stammering. 

Anomalies of the Genitourinary Function. — Enuresis; sexual irritability; 
impotence; sterility. 

Anomalies of the Instinct or Appetite. — Merycism; uncontrollable ap- 
petites for food, liquor, drugs, etc. 

Diminished resistance to external influences and diseases. 

Retardation of puberty. 

Psychical Stigmata. — Insanity; idiocy; imbecility; feeble-mindedness; 
eccentricity; moral delinquency; sexual perversion. 

REMARKS ON IDIOCY AND AMAUROTIC FAMILY IDIOCY 

Feeble-mindedness and imbecility are synonyms. By these terms we 
mean a condition of mental impairment due to either arrested development 
or disease of the brain. 

Pathology. — We find a number of abnormal conditions from which this 
usual classification is taken: 

1 . Cases depending upon arrested development of the whole brain or of 
the frontal lobes. 

2. Cases associated with hydrocephalus. 

3. Cases associated with microcephalus. 



768 



THE NERVOUS SYSTEM 



4. Cases associated with paralyses. There are different varieties of 
cerebral palsies, but the greater part are due to meningeal haemorrhage at 
the time of birth. In cases due to haemorrhage at birth there is spastic 
diplegia or paraplegia. Some cases are associated with acquired palsies, 
frequently due to meningeal haemorrhage. 

5. Some are of inflammatory origin, which follow a spinal meningitis. 
There may be some cases dependent on poliencephalitis. 

6. Some cases are associated with epilepsy. These are due to changes 
in the brain caused by repeated epileptic attacks. 

7. Sporadic cretins are idiotic. 

Heredity, alcoholism, syphilis, family nervous diseases, other vices of 
parents, and intermarriage of blood relations have some relation to con- 
genital idiocy. 

Some stigmata of degeneration are found in most cases. Howe examined 
517 idiots. Blindness was found in 21; deafness in 12; some defect in the 
nose or mouth, such as hare lip, high palatal arch, or cleft palate, in 23; 
some deformity of the hands or feet in 54; and paralysis of one or more 
limbs in 96. 

Amaurotic Family Idiocy 

This is a remarkable form of infantile paralysis with blindness occurring 
mostly in Hebrew children. 

Pathology. — The cerebral convolutions are primitive in type, there are 
degenerative changes in the large pyramidal cells, absence of tangential 
fibres, and a decrease of the fibres in the white matter. The blood vessels 
are normal. The pyramidal columns of the cord are also degenerated. 

Symptoms. — 1. Psychic disturbances appearing in early life (first or 
second year) and progressing to total idiocy. 

2. Paresis and ultimately complete paralysis of the extremities, which 
may be either flaccid or spastic. 

3. Increased, decreased, or normal tendon reflexes. 

4. Partial, followed by total blindness (macular changes, with subsequent 
atrophy of the optic nerve). 

5. Marasmus and death, usually before the second year. 

6. A distinct family type. 

Occasional symptoms are nystagmus, strabismus, hyperacusis, or im- 
pairment of hearing. Sachs collected twenty-seven cases, and of these, 
seventeen occurred in six families. All were Hebrews. 



CHAPTER XXVIII 



DERMATOLOGICAL MEMORANDA 

Synopsis: Introductory Remarks. — Anomalies of Pigmentation. — Diseases of the Sweat and 
Sebaceous Glands. — Eruptive Fevers (see Chapter on Pediatrics). — Inflammations, 
Eczema, Ulceration, Phlegmon, Atrophies, etc. — Parasitic Skin Diseases, Benign and 
Malignant Neoplasms, Dermatoneuroses. — Diseases of the Appendages (Hair, Nails). — 
Formulary. 

INTRODUCTORY REMARKS 

The skin performs various important functions. It is endowed with the 
power of respiration, by means of which there is a constant, although very- 
subordinate, interchange of oxygen and carbonic acid. 

The secretory junction of the skin is performed by the sweat and sebaceous 
glands. Sweating may be profuse or scanty, localized or general, or altered 
in color or smell. The secretion of sweat is not a continuous process, but 
is influenced or affected by many factors. The secretion of the sebaceous 
glands is probably continuous. The skin has a vasomotor heat regulating 
function which influences the radiation of heat and evaporation of moisture 
from the surface. The sensory function of the skin is a most important one. 
The color of the skin varies according to race, exposure, occupation, and the 
general state of health. We recognize the habitual pallor of indoor life and 
the pallor of anaimia from any cause. Localized or diffused redness may be 
physiological or pathological. A localized or general cyanosis may result 
from respiratory or circulatory embarrassment or from intoxication (acet- 
anilide poisoning, etc.). Yellow discoloration of the skin may result from 
obstructive or toxsemic jaundice. A bronzing of the skin is associated 
with the so called Addison's disease. A gray discoloration (argyria) has 
been observed after the long continued internal administration of silver 
salts. The temperature of the skin may vary considerably; the whole or 
a portion of the integument may be warm or cold. 

The skin receives the brunt of the bodily injuries and protects under- 
lying organs and tissues. Skin diseases are due to infection and auto- 
intoxication from the gastrointestinal tract. Many skin phenomena are 
simply the expression of an effort to eliminate. 

An unbroken skin or mucous membrane is an effective barrier to local 
and systemic infection by animal and vegetable microorganisms. The 
lymph nodes are an efficient ally in repelling microbial invasion by catching 
in their meshes infecting material; they generally participate also in the in- 
flammatory and destructive processes which threaten the skin. The vulner- 
ability of the skin from within, i. e., from internal conditions and causes, 

769 



770 



DE RM ATO LOGICAL MEMORANDA 



should always be borne in mind (eliminative rashes) in contradistinction to 
skin lesions which come from without the body. 

The classification of skin diseases is unsatisfactory to such an extent 
that in some publications the group classification has been dropped and skin 
lesions are described in alphabetical order. Although faulty and unsatis- 
factory, the author gives preference to a clinical grouping of skin lesions. 

As the diagnosis and management of skin diseases cannot be taught from 
books, however elaborate and voluminous, the definition, characteristic 
signs, and treatment of skin lesions are presented in a condensed form. At 
the end of the chapter a number of well tried formulae are given, and their 
selection is to be accomplished by means of reference numbers. 

Diet is important in skin diseases, but there are no formulated diet rules 
for universal application. The person afflicted with a skin lesion should 
avoid food which experience has shown does not agree with digestion or 
with the skin. Alcohol is harmful in many skin diseases; tobacco is less 
harmful. Climate and air have their influence, but no general rules can 
be laid down. 

Soap and water may act as an irritant in skin lesions, particularly in 
eczemas, and when washing cannot be avoided a small quantity of sal soda 
may be dissolved in the wash water. 

Dyspeptic and anaemic conditions and constipation should receive fore- 
most attention, and syphilis as an underlying cause of skin lesions should 
not be overlooked. 

DISEASES OF THE GLANDULAR APPARATUS 

SWEAT GLANDS 

Anidrosis. — Diminution or suppression of sweat. 

1. Primary, due to faulty innervation. 

2. Secondary, or symptomatic, as in diabetes, fevers, etc. 
The prognosis depends upon the underlying cause. 

Treatment. — Massage, vapor and alkaline baths, and enteroclysis may 
be of use. 

Bromidrosis (Osmidrosis). — This is the secretion of sweat of an offensive 
odor. The cause is unknown. It may be symptomatic, as in uraemia, 
rheumatism, etc. It mostly occurs upon the feet of young persons. The 
prognosis is favorable. 

Treatment. — Bathe in hot water and soap every night, and dust with 
talcum powder medicated with formalin (10 drops to 1 oz.). 

Chromidrosis (Colored Sweat). 

1. Idiopathic, due to obscure disorder of the sweat glands. 

2. Accidental, due to absorption of certain substances into the system. 
Green sweat is often found in copper workers. 

Red sweat is caused by Bacterium prodigiosum. 
The prognosis is bad in the first, but good in the second variety. 
Treatment. — Removal of the cause, symptomatic management. 
Haematidrosis (Bloody Sweat). — Haemorrhage from the sweat pores. It 
occurs in hysterical women. 



SEBACEOUS GLANDS 



771 



The prognosis is favorable. 
The treatment is symptomatic. 

Hyperidrosis, excessive secretion of sweat, may be general or local. The 
hands, if affected, are cold and clammy. If the feet are affected, the skin 
is macerated and walking produces pain. It is usually due to vasomotor 
disturbance. 

The prognosis is favorable. 

Treatment. — See Bromidrosis; use also camphor ice and ichthyol be- 
tween the toes as an ointment. 

SEBACEOUS GLANDS 

Acne (Pimples). 

1. Acne Albida (Milium, Grutum, Strophulus Albidus). — The lesions are 
minute rounded, opaque white, seedlike grains — distended sebaceous 
follicles — occurring mostly on the face, the eyelids, the scrotum, and the 
lower surface of the penis. 

The prognosis is favorable. 

Treatment. — Puncture the little cysts, turn out the contents, and 
destroy the remaining cyst wall by painting with iodine. 

2. Acne Punctata (Papulosa, Atrophica, Hypertrophia, Cachecticorum, 
Pustulosa, Indurata). — A pinhead to pea-sized papular and pustular erup- 
tion, mostly penetrated by a minute sebaceous plug, comedo, occurs on the 
forehead, face, and shoulders. It is mostly a disease of puberty, and often 
secondary to gastrointestinal and genitourinary disturbance or to. anaemia. 

Prognosis. — It is a very chronic affection, giving rise to marked nodular 
induration. 

Treatment. — Attention should be given to the removal of constitutional 
causes. Prescribe local bathing with hot water and occasionally with soap 
and application of formula No. 8. Puncture the pustules as they form. 

3. Acne Rosacea (Gutta Rosea). — The nose and face are hyperaemic and 
greasy and traversed by irregular tortuosities of blood vessels and isolated 
papules and pustules. Hypertrophy of the skin is present (pseudoelephan- 
tiasis). The constitutional causes are similar to those of the preceding 
variety; besides, it often appears during the menopause. It may also be 
caused by abuse of spirituous liquors and constant exposure to the weather. 

The prognosis is favorable under early and persistent treatment. 

Treatment. — Search for and remove the constitutional causes. Locally 
formula No. 25 is to be applied during the day and No. 24 at night. Perform 
scarification of the tortuosities, if they are very marked. 

Comedo (Acne Punctata Nigra, Black Heads, or Flesh Worms). — These 
are minute sebaceous plugs with black, yellow, or brown external points. 
They occur mostly on the face, neck, chest, and back. If not squeezed out, 
they are apt to give rise to an acnelike eruption. The cetiology is obscure, 
but is partly the same as that of acne. 

Prognosis. — They are very obstinate, but the outlook is favorable. 

The treatment is the same as in acne punctata. Locally, use for- 
mula No. 25. 



772 



DERMATOLOGICAL MEMORANDA 



Seborrhea (Acne Sebacea ; Tinea Furfuracea ; Dandruff) 

1. Seborrhoea Oleosa. — This is an inordinate oiliness of the skin of the 
forehead, nose, and cheeks; it is not attended by itching. 

2. Seborrhoea sicca gives rise to an accumulation of yellow or grayish 
scales upon the scalp or non-hairy regions. It is attended with decided 
itching. When the face is involved, the eyebrows and beard are affected 
first. When the scalp is affected it is frequently a source of premature 
baldness (defluvium capillorum). 

The prognosis is favorable, though the course is chronic. 

Treatment. — In seborrhoea oleosa, use astringent lotions, e. g., formula 
No. 27. In seborrhoea sicca the scales are to be removed by prolonged 
applications of olive or castor oil, the surface is washed with green soap, and 
then the hair wash, No. 47, is to be used. 

ANOMALIES OF PIGMENTATION 

CHLOASMA; VITILIGO; LENTIGO; ALBINISMUS 

Chloasma (Liver Spots, Moth). — Fawn-colored, yellowish, brownish, or 
blackish [melanoderma) patches of various sizes, irregular, rounded with 
fairly defined borders, may form on any part of the body. a. The idiopathic, 
due to external causes, may include all pigmentations resulting from local 
irritants, such as burns, blisters, etc., and scratching, b. The symptomatic 
is secondary to visceral and uterine diseases and occurs in pregnancy, Addi- 
son's disease, malarial disease, cancer, tuberculosis, etc., also from the pro- 
longed administration of silver (argyria). 

Treatment. — Remove the cause. Formulae Nos. 1 and 10. 

Vitiligo (leucoderma) consists of rounded, oval, or irregular, milk white 
or pinkish white spots, spreading slowly or rapidly, at times coalescing and 
forming large patches, the surrounding skin being usually brownish yellow. 
It is of slow progress, lasts throughout life, affects any part of the body, 
especially the backs of the hands and the trunk, is frequent in negroes, and 
may be associated with morphcea, alopecia areata, and exophthalmic goitre. 

Treatment. — Give arsenic internally, also iodine, and use weak lotions 
of acetic acid or corrosive sublimate locally. 

Lentigo (freckles), due to an increased deposition of pigment in the 
basal layer of the epidermis, we observe mostly on the face and hands in 
individuals of fair complexion. The lesions are pinhead to pea-sized, round, 
oval, or irregular, and of a yellowish, brownish, or blackish color. 

Treatment. — Use formulae 9 or 10, and particularly 42, 43, 44, and 45. 

Albinism is a lack of pigmentation. 

INFLAMMATIONS 

Bedsores (decubitus) are caused by undue pressure and irritating secre- 
tions with underlying constitutional or trophoneurotic changes. Patho- 
logically they may be looked upon as local patches of moist gangrene. They 
are common in the course of various wasting diseases and fevers, and es- 
pecially in the course of lesions of the brain and spine. 



DERMATITIS 



773 



Treatment. — Harden the skin by means of alcohol or spirit of camphor 
and reduce the pressure by air cushions or a water bed. If ulcers develop, 
treat them antiseptically. 

Ulcer of the Leg. — Eczematous, senile, from varicose veins, syphilitic, 
tuberculous, carcinomatous, etc. 

Principles op Treatment of Simple Ulcer. — Cleansing of the parts. 
Rest in bed and a lead lotion if the ulcer is inflamed. If it is not inflamed, 
cauterize or remove with 
a sharp spoon all foul 
granulations or debris, 
and dress with zinc ad- 
hesive plaster or zinc and 
ichthyol ointment or 
plain mutton suet. If the 
patient is obliged to be up 
and about, he should wear 
an elastic bandage over 
a thin summer stocking, 
with the toe end cut off. 
Almost all ulcers can be 
healed. 

DERMATITIS 

Dermatitis calorica 
(burns) results from ex- 
posure to the sun (ery- 
thema or eczema solare, 
"sun burn"), to radiating 
sources of heat (x rays), 
or to heated solids or 
fluids. The degree of the 
burn depends upon the 
duration of the exposure, 
the degree of heat, and 
the resistance and sensi- 
tiveness of the skin. 
There is erythema, tume- 
faction, vesiculation, or 
partial or complete de- 
struction of the skin. There may be desquamation, with consequent pig- 
mentation or scarring. There is a tendency to severe septic complica- 
tions, and in large, especially abdominal, burns ulceration of the duo- 
denum is apt to occur, with perforation, etc. There is shock even in 
slight burns. 

The prognosis is favorable in mild burns, but very unfavorable if more 
than a third of the entire body surface is affected. 

Treatment. — Relieve pain and shock. Keep the burnt surface clean. 
Apply sedative lotions, powders, and ointments — carron oil, zinc and starch 
powder, and formulae Nos. 21 and 36. 




Fig. 215. — Dressing for Ulcer op the Leg. 
Absorbent gauze in position over rubber tissue — roller 
bandage securing dressing. The gauze is turned back to 
show the rubber tissue beneath. (Dr. W. S. Schley, the 
Med. Record, 1904.) 



774 



DERMATOLOGICAL MEMORANDA 



Congelatio (frostbite) pernio (chilblain) affects chiefly the exposed 
parts of the body, also the feet. Depending upon the degree of cold, the 
color and condition of the skin may vary from a temporary vivid hue to a 
dead white (" marbleized") color. There is insensitiveness, with stiffness 
and necrosis, the latter necessitating at times amputation of frozen fingers 
or toes. 

The prognosis is favorable in mild and grave in severe frostbites. 

Treatment. — Use friction with snow and towels soaked in ice water; 
if ulceration and gangrene set in, treat antiseptically, formula No. 37. In 
severe cases surgical interference may be required. 

Dermatitis Gangraenosa Adultorum (Dermatitis Diabetica). — It is usually 
associated with diabetes mellitus. It is a bulloserpiginous form of gangrene, 
occurring sometimes in successive crops on the limbs. The bullae dry in the 
centre into a scab enclosed by a ring of pus. 

Prognosis. — This depends upon the general condition of the patient, 
but the trouble is rarely sufficiently extensive to be fatal of itself. 

Treatment. — Locally, use antiseptic lotions; internally roborants and 
attention to the underlying cause. 

Dermatitis Gangraenosa Infantum (Varicella Gangrenosa, Pemphigus 
Gangraenosus). — This follows aggravated cases of varicella, vaccinia, or 
other severe pustular eruptions. It is characterized by papulopustules 
which dry into scabs, surrounded by narrow pustular rings and these again 
by bright red areolae. They coalesce in large patches and form ulcers. 

The prognosis is usually favorable, but the disease may end fatally 
from secondary septic infections. 

Treatment. — Employ local antisepsis, as with lotions or salves of boric 
acid, and tonics internally, with enteroclysis and fresh air to breathe. 

Dermatitis Medicamentosa — Drug Eruptions. — Under this title are in- 
cluded the several eruptions due to the ingestion and absorption of certain 
medicaments. Idiosyncrasy, large doses, and long continued administra- 
tion are the chief factors in the production of these eruptions and other 
manifestations. The principal drugs, with their cutaneous results, are as 
follows: 

Acetanilide. — Cyanosis. 

Antipyrine. — Usually symmetrical erythema, mostly on the extensor 
surfaces. 

Antitoxine. — Roseola, erythema, and occasionally urticaria. 
Arsenic. — Urticarial, erysipelatoid dermatitis, or a papular rash; and in 
large doses, a pustular, ulcerative, or gangrenous eruption. 
Belladonna. — Erythematous and scarlatiniform eruptions. 
Boric Acid. — Erythema. 
Borax. — Psoriasis, erythema, and eczema. 

Bromine and Bromides. — Pustular, urticarial, bullous, and squamous 
eruptions. 

Cannabis Indica. — A vesicular eruption. 
Chloroform. — Purpura. 

Chloral Hydrate. — Erythema and bullous and erysipelatoid eruptions. 
Cod Liver Oil. — Acne and a vesicular eruption. 
Copaiba. — Erythema, urticaria, or a papular eruption. 



DERMATITIS 



775 



Cubebs. — A papular eruption. 
Digitalis. — Erythema. 

Iodine and Iodides. — Pustular, vesicular, purpuric, erythematous, and 
urticarial eruptions. 

Iodoform. — Papular and erythematous eruptions. 
Mercury. — Erythema. 
Morphine. — Erythema. 

Phosphoric Acid. — Purpuric and bullous eruptions. 
Quinine. — Erythema and urticaria. 
Rhubarb. — Hemorrhagic and pustular eruptions. 
Salicylic Acid. — Erythema, urticaria, and eczema. 
Santonin. — Urticaria. 

Strychnine. — Miliaria, a scarlatiniform eruption, and pruritus. 

Tannin. — Urticaria. 

Tar. — Erythema and acne. 

Terebene and Turpentine. — Erythema and a papular eruption. 
Tuberculin. — A scarlatiniform eruption. 

Treatment. — This comprises removal of the cause and palliative 
treatment. 

Dermatitis Multiformis Herpetiformis (Hydroa Herpetiformis). — This is 
manifested by a conglomeration of erythematous patches, urticarial wheals, 
maculopapules, vesicles, and pustules. The multiformity and changeability 
of the lesions, the traces of former lesions in the shape of pigmented areas, 
the presence of intense and persistent itching out of all proportion to that of 
the eruption, the frequency of exacerbations, and the extreme obstinacy of 
the disease are the only aids in diagnosis. 

No part of the skin is exempt from this eruption. 

The prognosis is not promising; the course is very chronic. 

Treatment. — Guard against all excesses, including overwork of body 
and mind, and. correct faulty digestion. Prescribe outdoor exercise, recre- 
ation, and tonics, formulae Nos. 1, 2, and 19. 

Dermatitis Traumatica. — This is an inflammation of the skin produced 
by mechanical injury, such as erosion, abrasion, contusion, compression, in 
fact every grade of inflammation, from simple erythema to abscess and 
gangrene. 

Treatment. — Treat mild cases by a simple antiseptic dressing; in severe 
cases surgical interference may be required. 

Dermatitis venenata is produced by the contact of chemicals, caustics, 
or other irritants; to the latter group belongs the dermatitis resulting from 
exposure to poison ivy (Rhus venenata) and poison oak (Rhus toxicodendron). 
Special idiosyncrasy plays a very important role. The disease comes on 
within some hours after exposure, with a sensation of heat and itching ex- 
perienced in the face and hands first, and in all other portions of the body 
which come in contact with the affected hands next. Reddening, tume- 
faction, vesiculation, exudation, and severe oedema soon follow. 

The prognosis is favorable; the duration is about one week. 

Treatment. — Remove the cause, and apply cooling lotions (lead lotion) 
and powders, formula; Nos. 3, 13, 32, and 35; later also ointments, formula 
No. 23. 

50 



776 



DERMATOLOGICAL MEMORANDA 



ECTHYMA 

The lesions are flat pustules, pea to bean-sized, first yellowish, then 
reddish, upon an inflamed base, with crusting, heat, pain, and burning. 
They are mostly distributed on the thighs, legs, shoulders, and back. 

The prognosis is favorable. 

The treatment is constitutional, with tonics and cleanliness. Formula 
No. 4. 

ECZEMA (TETTER; SALT RHEUM; SCALL) 
This is an acute or chronic inflammatory disease of the skin. The 
eruption varies with the particular variety of the affection and its situation. 
Hypersemia, oedema, burning, and itching are present in all varieties. In- 
filtration is the chief character- 
istic of chronic eczema. 

Eczema Erythematosum. — 
There is a diffuse or circum- 
scribed erythema of the sur- 
face, with a yellow tinge, oc- 
curring on the face and nose. 

Eczema Papulosum. — The 
lesions are minute dull red 
papules on the extensor aspects 
of the limbs, the back of the 
trunk and neck, the buttocks, 
etc. 

Eczema Vesiculosum. — Ves- 
icles occur on the face, between 
the breasts, on the hands, etc., 
and there is exudation with 
yellow crusting. 

Eczema pustulosum usually 
begins like the variety last men- 
tioned, the fluid soon changing 
into pus; the lesions occur on 
the scalp and face. 

Eczema rubrum is charac- 
terized by bright red patches and serous exudation (a "weeping surface") 
upon the legs of adults and the face of infants. 

Eczema Squamosum. — Scaly patches are seated on an inflamed base. 
The course is very chronic. It occurs mostly on the outer aspects of the 
extremities. 

Eczema fissum is marked by fissures between the fingers and toes and at 
the articulations. 

Eczema sclerosum (keratosis) is a localized leathery infiltration occurring 
on the palms, soles, finger tips, etc. 

Eczema Verrucosum. — There is hypertrophy of the papillae, giving rise 
to a warty surface. 

The prognosis varies. Some cases aid quickly in recovery; others per- 
sist for life. 




Fig. 216. — Gauze Mask and Splints to Pre- 
vent Scratching in Eczema. 



ERYTHEMA AND HERPES 



777 



Treatment. — Acute Eczema. — Cleanliness is of primary importance. 
Prevent scratching by masks of gauze or bandages and by means of cellu- 
loid sleeves. Reduce inflammation by lead lotion or soothing ointments. 
Use prescription No. 21, or mutton tallow. Give laxatives internally. 

Chronic Eczema. — Remove or treat the constitutional causes, such as 
syphilis and intestinal toxaemia (laxatives). Soften the crusts with wet 
carbolic dressing (1 to 60) or oil over night. Apply stimulating ointments. 
Use formula? Nos. 1, 4, 19, or soothing ointments, such as mutton suet, 
zinc, bismuth ointment, or stearate of zinc with acetanilide (dusting powder) 
or yellow oxide of mercury ointment, gr. x to 5j- Internally, give arsenic 
or potassium iodide in obscure cases. 

ERYTHEMA 

Erythema simplex is identical with simple dermatitis (q. v.), but 
milder in degree. 

Erythema Intertrigo (Chafing). — The skin is red, hot, moist, and macer- 
ated, and the disease may terminate in dermatitis or eczema. It occurs in 
regions where surfaces are in apposition, e. g., the nates, groins, axillse, 
mamma?, etc. 

Erythema Multiforme. — The lesions are of various sizes and shapes, 
consisting of macules, papules, blebs, vesicles, etc. It is mostly symmetrical. 
It often appears simultaneously on the backs of hands and feet. It has an 
acute course, with no scaling. There is some constitutional disturbance, 
with moderate itching. It seems to be an eliminative phenomenon in acute 
and chronic intestinal indigestion. 

Erythema Nodosum. — Symmetrically distributed round or oval, rosy 
red, shining nodules, of the size of a walnut up to that of an egg, occur oyer 
the tibia, forearms, thighs, face, back, tongue, and pharynx. The duration 
is from seven to ten days. There is no suppuration. There are constitu- 
tional symptoms, with articular pains and swelling. 

The prognosis is generally favorable. 

The treatment depends greatly upon the cause. Formulae Nos. 23 and 7. 

HERPES 

Herpes simplex (fever blisters) consists of a small cluster of vesicles, 
first clear, then cloudy, which dry into crusts. They tend to coalesce, and 
they disappear without scar. It is situated on any portion of the face 
(herpes facialis) , about the lips (herpes labialis) , or on the prepuce of the male 
and the labia majora or minora of the female (herpes progenitalis). There 
are burning and itching. 

Herpes Zoster (Shingles). — Groups of vesicles form on a bright red, highly 
inflamed base, usually along the tract of a nerve, with neuralgic pains. 
It is unilateral. There is a tendency to coalesce, with the formation of 
yellowish brown crusts. In herpes zoster ophthalmicus severe damage to 
the eye may occur. 

The prognosis is generally favorable, but there is a tendency to recur- 
rence. 

Treatment. — Camphor ice or formulae Nos. 3, 7, 11, or 17. 



77S 



DERMATOLOGICAL MEMORANDA 



IMPETIGO 

Impetigo Simplex. — There are one or more distinct yellowish pustules, 
of the size of a split pea, surrounded by an areola and terminating by ab- 
sorption or crusting. There is no itching. 

Impetigo Contagiosa. — Discrete fiat superficial vesicles or blebs form, 
soon turning into pustules, which rupture and dry up as waferlike crusts 




Fig. 217. — Contagious Impetigo. 
(By Courtesy of the Amer. Jour, of Obstetrics.) 



("stuck on"), curl up, and drop off, leaving behind reddish spots. There is 
a tendency to umbilication and coalescence. 

The prognosis is favorable. 

Treatment. — Formulae Nos. 1, 2, 4, and 15. 

ICHTHYOSIS (FISH SKIN DISEASE) 

This is congenital or begins in early life. It is worse in cold weather. 
It often affects several members of one family. 

Ichthyosis simplex involves the greater part of the body. The skin is 
dry and harsh with scales, either furfuraceous or large and thick, resembling 
fish scales. 

Ichthyosis hystrix is rarer and more severe. There is papillary hyper- 
trophy showing itself by irregular or linear corrugated, warty or spinous, 
horny patches. 



LICHEN — MILIARIA — PEMPHIGUS (WATER BLISTERS) 779 



Prognosis. — The course is extremely chronic. 

Treatment. — Use hot baths with green soap, also glycerine and for- 
mulae Nos. 16 and 20. 

LICHEN 

Lichen Ruber Acuminatus. — Discrete, millet seed-sized, acuminated, 
scaly, reddish papules are disseminated over the trunk, with no disposition 
to grouping. There is severe itching. 

Lichen Ruber Planus. — First Stage. — There are minute, reddish, irregu- 
larly shaped, sharply defined papules with flattened surface, brilliant under 
oblique rays of light. Second Stage. — Confluence of the papules occurs, 
forming plaques (4 mm. to 1 cm. in diameter) of a brownish red color with 
fine gray scales. Third Stage. — There is thickening of the derma, with white 
striation upon a red base and distinct grouping, usually upon the flexor 
surfaces of the forearm and wrist, the lower portion of the abdomen, the 
lumbar region, the lower extremities, etc., and itching. 

Prognosis. — The acuminate form, if neglected, may constitute a very 
serious disease. Lichen ruber planus is in the main benign and may 
undergo spontaneous cure. 

Treatment. — Give arsenic internally, with attention to the nervous 
system. Locally, use tepid douches, from 95° to 100° F., to be continued 
from two to five minutes, also mercurial plaster or ointment. Formula No. 
33. 

MILIARIA (SUDAMINA; PRICKLY HEAT) STROPHULUS 

This is characterized by minute red or whitish papules, of a sudden ap- 
pearance, accompanied by pricking or tingling. 
The prognosis is favorable. 

Treatment. — Use cooling lotions, such as liq. plumb, subacet. dil., and 
formula No. 28. 

PEMPHIGUS (WATER BLISTERS) 

Pemphigus Simplex. — There is a successive development of crops of pea- 
sized to egg-sized blebs, distended with a colorless fluid, which changes 
to yellowish or hsemorrhagic as the eruption grows older. 

Pemphigus Foliaceus.— There are flaccid and purulent blebs which rup- 
ture early, leaving an excoriated, "scalded" surface. There is a tendency to 
spread over the whole body, including the mucous membranes, hair, etc. 
It may end fatally. 

Pemphigus Neonatorum. — Simplex non-syphiliticus. 

Pemphigus Neonatorum Syphiliticus. — The prognosis in pemphigus 
simplex is favorable, while pemphigus foliaceus leads almost invariably 
to a fatal termination. 

Treatment. — Use arsenic and tonics internally. Puncture the blebs 
and apply soothing lotions or ointments in severe cases. Prolonged im- 
mersion of the patient in a warm medicated bath may be employed, or 
iodide of potassium and mercury given in the specific form. 



780 



DERMATOLOGICAL MEMORANDA 



PITYRIASIS 

Pityriasis Rosea (Pityriasis Maculata and Circinata). — There are patches 
and circles barely elevated above the surface, pale red in color, covered by 
very fine scales, usually on the trunk and upper segments of the limbs, with 
slight itching. 

Pityriasis Rubra. — There is redness of the skin, with an abundance of 
thin, papery exfoliation. The patches are circumscribed and symmetrical 
and spread peripherally over the whole body. There is a tendency to 
marasmus. 

Pityriasis rubra pilaris affects the orifices of the hair follicles, especially 
of the anterior surfaces of the limbs, leaving the intervening skin intact. 
The root of each hair is surrounded by a small, hard, conical elevation com- 
posed of minute adherent scales. The skin is dry and rough (" goose skin"), 
and there is slight itching. 

The prognosis is favorable, but recurrences are frequent. 

Treatment. — Use formulae Nos. 2, 21, and 34. 

PRURIGO 

Prurigo Mitis. — There are circumscribed, individualized, reddish, conical 
papules, with minute vesicular summits, which dry up and leave behind 
small brownish crusts. They usually occur on the extensor surfaces of 
the legs and arms, on the trunk, and sometimes on the forehead. There 
are tingling, pricking, burning, and shooting pains, worse at night. There 
is a successive development of new crops. 

Prurigo ferox usually begins in very early life, often following an ordinary 
urticaria. It may persist throughout an entire lifetime. The initial 
symptoms resemble those of prurigo mitis. The skin gradually becomes 
harsh, dry, hypertrophied, and pigmented, with inflammation of the neigh- 
boring glands. 

The prognosis is dubious, recovery being possible, although the course 
is very chronic, with a tendency to be complicated by chronic eczema. 

Treatment. — Prescribe a bland diet, and order arsenic, and pilocar- 
pine internally. Externally, use fresh styrax ointment. Formulae Nos. 5 
and 15. 

PSORIASIS (LEPRA ALPHOS) 

This begins with minute white spots, usually on the elbow, knees, and 
scalp, gradually spreading in size and location, exhibiting incrustations of a 
mother of pearl-like or silvery lustre, based upon tawny red, slightly elevated 
patches of the skin. There is very slight itching. 

Psoriasis Guttata. — There are small rounded patches, giving the skin the 
appearance of having been splashed with mortar. 

Psoriasis Nummulata. — The eruption resembles coins of various sizes. 

Psoriasis circinata is characterized by annular patches, clear in the centre. 

Psoriasis Gyrata. — There are wavy lines about half an inch wide with 
circles and semicircles. 

Psoriasis Diffusa. — The eruption is extensive and irregular, covering 
large surfaces. 



URTICARIA (HIVES; NETTLE RASH) 



781 



Prognosis. — It may be removed for a time by appropriate treatment, 
but it is almost sure to return. 

Treatment. — Give arsenic internally. Remove the scales by warm 
alkaline baths. The severer the inflammation the milder the remedy, and 
vice versa. Formulae Nos. 1, 4, 16, and 19. 

SCLEREMA NEONATORUM 

The disease develops soon after birth, showing spots of circumscribed 
hardness. The skin is waxy, glistening, hard, and cold; the limbs become 
stiff and misshapen; the temperature is subnormal; and there are weakness, 
somnolence, rapid breathing, and a feeble pulse. 

Prognosis. — Death occurs within three or four days; rarely there is 
gradual recovery. 

Treatment. — We may use artificial heat, massage with warm oil, and 
nutritious and careful feeding. 

SCLERODERMA (HIDE-BOUND DISEASE) 

This is a disease of the adult, characterized by pronounced stiffening or 
hardening of the skin, which feels like frozen skin, leather, or even wood. 
The hue is yellowish or brownish, and the induration is followed by atrophy. 
Often ankylosis of phalangeal joints (sclerodactylia) occurs. If it remains 
circumscribed in form, it is known as morphoea; the latter may manifest 
itself as atrophic pitlike depressions in the skin and as lines, streaks, and 
telangiectasis. 

Prognosis. — It may undergo spontaneous involution or persist through- 
out life. 

Treatment. — Use tonics internally, massage with warm oil, and employ 
electricity locally. 

URTICARIA (HIVES; NETTLE RASH) 

There is a sudden appearance upon any portion of the body, as well as 
a sudden disappearance, of "wheals" of a whitish, pinkish, or reddish color, 
accompanied by stinging, pricking, and tingling, and with slight consti- 
tutional symptoms. 

Urticaria annularis occurs in rings. 

Urticaria figurata occurs in spirals. 

Urticaria vesiculosa shows vesicles on the summit of the wheal. 
Urticaria bullosa shows a bullous development on the summit of 
the wheal. 

Urticaria Papulosa. — The wheal is combined with a papule. 
Urticaria tuberosa is manifested by giant wheals. 
Urticaria haemorrhagica is a combination of urticaria with purpura. 
Urticaria pigmentosa is marked by pigmentation following the wheals. 
Urticaria Chronica Infantum. — See Strophulus. 

The prognosis for urticaria is favorable, but recurrences are frequent. 

Treatment for Urticaria. — Correct faulty digestion with an aloin 
pill at night and 5 gtt. of hydrochloric acid after eating. Externally, use 
formula No. 5 or 32. 



782 



DERMATOLOGICAL MEMORANDA 



XERODERMA (XEROSIS) 

There are congenital dryness, harshness, and roughness of the skin, with 
scaly desquamation and dull, grayish, dirt-colored discoloration, chiefly 
involving the temples and extremities. It appears usually within the first 
two years of life. 

The prognosis is unfavorable. 

The treatment is palliative. 

PARASITIC SKIN DISEASES 

A. ANIMAL 

Pediculosis (lousiness). 

Pediculosis capitis occurs mostly on the occipital portion of the head, 
with the presence of ova, or nits, and pediculi; there is itching, with conse- 
quent scratch marks. 

Pediculosis corporis occurs mostly on the scapular region, chest, abdomen, 
hips, and thighs. There are red dots, pustules, itching, and scratch marks, 

with pigmentation. Pediculi may be 
found on the body and in the clothes. 

Pediculosis pubis (crab louse) in- 
fests the pubes, axilla, sternal region, 
beard, eyebrows, and lashes. There is 
a pruriginous eruption. 

The prognosis is favorable. 
Treatment. — Scrub the parts with 
hot water and green soap, and apply 
formulae Nos. 15, 20, 22, and 38 or pe- 
troleum. 

Scabies (Itch). — There are whitish 
or yellowish dotted, linear elevations 
Fig. 218.— Pediculus Pubis. (burrows) of the epidermis, produced 

by the burrowing process of the para- 
site, the Acarus or Sarcoptes scabiei, which can be discovered microscopi- 
cally. There are papules, vesicles, and pustules, with excoriations and 
scratch marks. There is violent itching, worse at night. It chiefly affects 
the hands, the sides of the fingers and the folds between them, the wrists, 
the mammae, the nipples, and the penis. 
The prognosis is favorable. 

Treatment. — Scrub the parts with green soap and hot water, and apply 
formula No. 19 or 22 or tincture of iodine. 

B. VEGETABLE 

1. Blastomycetce (Yeast Fungi) 

Skin actinomycosis, due to the actinomyces, or ray fungus, is character- 
ized by tumors along the sides of the face and lower jaw, which are livid and 
later dark in color; they rupture and discharge sulphur — yellow, sagolike 




ALOPECIA 



783 



particles composed of masses of the parasite. There are constitutional 
symptoms. 

The prognosis is favorable if the affected parts can be reached and 
removed perfectly. It may result fatally if internal organs are involved. 

Treatment. — Destroy localized foci by surgical methods, scarification, 
cauterization, actual cautery. 

Mycetoma (Madura Foot). — A single papule or pustule occurs on the 
sole of the foot or on a toe or finger, which enlarges and breaks; similar 




Fig. 219. — Male and Female of Sarcoptes Scabiei (Braun). 



lesions gradually involve the entire limb, leaving behind sinuses which dis- 
charge yellow or black masses, resembling fish roe, which contain the fungus. 

The prognosis is favorable as to life, but the disease is very tedious and 
distressing. 

Treatment. — Surgical methods, such as cauterization, must be used. 

2. Hypomycetce (Mould Fungi) 
Alopecia areata parasitica (see Alopecia). 

Myringomycosis (Fungous Disease of the External Ear). — This is due to 
Aspergillus glaucus and niger. The middle and external meatuses of the 
ear are covered by a substance resembling dirty blotting paper, with small 
raised spots of a black, brown, green, or yellow color. The eruption is often 
glazed by a serous exudation. There are pain, stinging, and itching, and 
partial or complete deafness may result if the disease is neglected. 

The prognosis is generally good, but there is a tendency to relapse. 

Treatment. — Use parasiticides. Syringe with soap water and formalin 
water. 

Tinea trichophytina (ringworm) is due to a trichophyton fungus. 

Tinea Barbae (Sycosis). — There are scaly patches on the bearded surface, 
soon developing into numerous pustules and tubercles. The hairs become 
loose and brittle, and there are itching, burning, and pain. 

Tinea Capitis (Tonsurans). — There are circumscribed ring-shaped, slightly 
raised patches, reddish, grayish, or greenish yellow in color. The hairs 



784 



DERMATO LOGICAL MEMORANDA 



are loose or broken off close to the scalp, and there is rapid spreading of the 
patches. Soon baldness of the affected spots occurs (see Alopecia). At 
times it is accompanied by severe local inflammation with exudation of a 
viscid gelatinous secretion (tinea kerion). There is itching. 

Tinea Corporis (Circinata). — There occur small, circular scaly spots which 
spread rapidly peripherally and become clear in the centre, often attaining 
half an inch in diameter. Occasionally the "rings" coalesce, forming 
serpiginous lesions. The face, trunk, thighs (tinea circinata cruris), axilla, 
and nails (tinea unguium) are chiefly affected. 

The prognosis is good, but the course is chronic. 

Treatment. — Tinea Barbce. — Wash the face with hot boric or carbolic 
acid solution, and apply formula No. 1, 4, or 37, or, if the spots are dry, 
tincture of iodine. 

Tinea Tonsurans. — Formula No. 29, followed by formula No. 6. 

Tinea Circinata. — Paint with tincture of iodine or glacial acetic acid 
every second day or use formula No. 1 or 15. 

Tinea favosa is due to Achorion Schoenleinii. 

First stage: There are itching, redness of the skin, and furfuraceous 
desquamation of the cuticle of the scalp. Second stage: Small, isolated, 
dry, yellowish crusts form, gradually increasing in size and thickness and 
becoming depressed in the centre, forming "favus cups," and there is 
looseness of the hair. Third stage: There are large, irregular yellow in- 
crustations with baldness (see Alopecia), and the remaining hair becomes 
woolly. Fourth stage: The crusts become white, friable, and uneven, re- 
sembling pieces of crumbling mortar; there is a fcetid " mousy " odor. 

The prognosis is doubtful. 

Treatment. — Formula No. 29 followed by formula No. 6. 

Tinea Versicolor (Liver Spots) Due to Microsporon Furfur. — There are 
irregular spots, of the size of a small coin to that of a hand, variously colored, 
from delicate buff to deep brown, mostly on the chest, covered with fur- 
furaceous scales. The disease has erroneously been attributed to derange- 
ment of the liver. 

The prognosis is good. 

Treatment. — Apply formula No. 1 or 15 or tincture of iodine. 

Schizomycetce (Fission Fungi, Bacilli, and Cocci) 

Anthrax (malignant pustule) is due to Bacillus anthracis. A red pimple, 
like an insect bite, forms and is soon converted into a vesicle surrounded 
by red, brawny infiltration; around this there is a ring of secondary vesicles. 
There are severe induration, cedema, implication of neighboring glands, 
and constitutional symptoms. 

The prognosis is unfavorable without early energetic treatment. 

Treatment. — Use germicides externally and roborants internally. 
Surgical interference may be required. 

Carbunculus (Carbuncle). — There is a large, flat infiltration, from the 
size of a chestnut to that of an orange, usually on the neck or back, followed 
within a week by sloughing and exudation of sanious pus. There is a 
cribriform appearance of the surface, and there are constitutional symptoms. 



ELEPHANTIASIS, ERYSIPELAS, LEPROSY 



785 



The prognosis is generally good, if the disease is treated early. 

Treatment. — Surgical interference should be resorted to — early deep 
incisions and a moist antiseptic dressing. 

Elephantiasis (E. Arabum, Barbadoes Leg, Pachydermia). — This usually 
affects the leg and foot, also the genitalia. It begins as an erysipelatous 
inflammation, with fever, lymphangeitis, pain, etc., followed by a more or 
less permanent enlargement of the part. There are frequent recurrences of 
these attacks until a state of chronic hypertrophy is reached. Pigmenta- 
tion, fissures, and papillomatous growths form. 

The prognosis is unfavorable. 

The treatment is palliative. 

Erysipelas (the Rose). — This is due to Streptococcus erysipelatosus. Red 
spots form, rapidly spreading and coalescing, with oedema. The skin is 
tense and shining; at times there are also small vesicles and blebs, with 
constitutional disturbance, such as fever and delirium. 

Erysipelas (phlegmonous). — In this form there is infiltration of the 
areolar tissue. 

Erysipelas Ambulans. — This is characterized by involvement of dif- 
ferent portions of the body. 

The prognosis for erysipelas is uncertain. 

Treatment. — Give iron internally, 5 gtt. of tinct. ferri chloridi every 
two hours. Use a lead lotion externally or formula No. 21. Limit the 
spreading by demarcating the affected part by means of the nitrate of silver 
stick or superficial scarifications (fence rail) and a moist bichloride dressing. 

Furunculus (Boil). — Small, hard, rounded, reddish spots form, painful 
on pressure, developing within a week into a painful inflammatory swelling 
with a central suppurating and necrotic point, the "core." The pain is 
dull and throbbing. There are slight constitutional symptoms. 

The prognosis is favorable. 

Treatment. — First apply a moist dressing of hot tea leaves, then make 
an incision and apply a surgical dressing. 

Glanders (Farcy). — Due to the bacillus of glanders. It is a disease of 
horses, transmitted to man. There are small nodules which soon soften 
and break down, discharging a viscid grayish yellow or haemorrhagic 
material. The edges of the " bud" are swollen, ragged, and ulcerated, and 
enclose a craterlike base which is at times studded with tubercles. Sec- 
ondary abscesses form, and there are severe constitutional symptoms. 
Often there are respiratory lesions, with nasal ulceration and a foul smelling 
discharge. 

The prognosis is grave. 

The treatment is surgical. Give dilute Hcl and tonics internally. 

Leprosy (Lepra Vera; Black Leprosy). — Due to the lepra bacillus. 

Leprosy, Tubercular Form. — First Stage. — There are depression, 
debility, drowsiness, chilliness, profuse sweating, vertigo, and recurrent 
epistaxis, with a high temperature. 

Second Stage. — After days or months, there are oedema of the eyelids, 
erythema of the face, ears, and extremities, and well defined shiny, slightly 
raised patches. This is followed by crops of papules, reaching the size of a 
hen's egg, yellowish or brown in color. 



786 



DERMATOLOGICAL MEMORANDA 



Third Stage. — There are tubercular nodules on the face, limbs, breast, 
etc., also on the mucous membranes. A characteristic leonine expression of 
the face occurs as a result of hypertrophy. There is gradual ulceration of 
the skin with severe constitutional symptoms and exhaustion, and death 
occurs in from eight to ten years. 

Leprosy, Non-Tubercular (Anaesthetic Form). — First Stage. — The 
prodromes are similar to those of the other variety. 

Second Stage. — After about a year, pale yellow, flat spots, one or two 
inches in diameter, appear on the back, the shoulders, the posterior aspect 
of the arms, the nails, and the thighs, sometimes along the course of nerves. 
The eruption spreads peripherally, clears in the centre, and becomes dry, 
scaly, and anaesthetic. Atrophic changes follow. 

Third Stage. — Paralyses, ulceration, gangrene, loss of members by re- 
sorption of bone, marasmus, and death occurs within from fifteen to twenty 
years. 

Leprosy, mixed tubercular form, is a combination of both former 
varieties. Often there is destruction of cartilages of the nose and soft palate. 
The prognosis for leprosy is grave. 

The treatment is palliative. Give tonics, attend to the hygiene, and 
allow nutritious food. Good results are reported from chalmougra oil used 
internally and externally. 

Lupus. — Lupus Erythematosus (see Benign Neoplasms). 

Lupus V ulgaris (see Tuberculosis of the Skin) . 

Moluscum Contagiosum. — Discrete, semiglobular, waxy white, umbili- 
cated elevations, of the size of a split pea, containing a cheesy substance 
form, especially on the face, eyelids, hands, and neck. 

The prognosis is favorable. 

Treatment. — Squeeze out the contents. Formula? Nos. 1, 4. 

Rhinoscleroma. — This is characterized by the formation of flat, discrete 
or coalescent, hard, ivorylike plaques, deeply embedded in the mucous 
membrane or skin and sharply bounded from the adjacent healthy parts. 
The surface is reddish, smooth, and crossed by dilated blood vessels. Usu- 
ally it affects the alae nasi first, and then spreads upward into the ante- 
rior and posterior nares. It may affect also other portions of the naso- 
pharynx or the larynx. 

Prognosis. — The growth never breaks down spontaneously. 

Treatment. — Employ curetting, excision, and the galvanocautery. 

Syphilis of the Skin. — Primary Stage. — After an incubation period of 
from three to four weeks, a small grayish papule — chancre — develops which 
is depressed in the centre, indurated at the base, and covered by epithelial 
debris or a scanty secretion. There is involvement of the neighboring 
glands. 

Secondary Stage. — After from six weeks to six months, there appear a 
number of different forms of eruptions resembling roseola, eczema, acne, 
psoriasis, lichen, pemphigus, tuberculosis cutis, condylomata, rupia, ecthyma, 
etc. These eruptions are modified in syphilis by their coppery, or "raw 
ham," color, the presence of more or less pigmentation, their symmetrical 
arrangement, the circular or crescentic shape of the patches, absence of 
itching, absence of large and silvery scales, as seen in ordinary psoriasis, 





Fig. 220. — Papulo-Pustular Stphilide sent to Municipal Hospital as a Case 
of Smallpox. (After Welch and Schamberg.) 



and soles and flexor aspects of the limbs, and finally their polymorphism, 
the eruption being here papular and there pustular, etc. There are also 



788 



DERMATOLOGICAL MEMORANDA 



suppurative and deep ulcerating patches on the mucous membranes. The 
iris, periosteum, bones, joints, ear, and testicles may successively or simul- 
taneously become affected. There is marked involvement of the lymphatic 
glands. Syphilitic alopecia or onychia may occur. There are constitu- 
tional disturbances, especially headache at night, with prostration. 

Tertiary Stage. — This follows after a few months or years. Gummata 
may form in any structure or organ of the body, which may undergo case- 
ation or necrosis, continue indefinitely, or be absorbed under appropriate 
treatment; they may give rise to deformities, as when attacking the naso- 
pharynx, and to disturbances of the respiratory, circulatory, digestive, and 
nervous systems, the manifestations depending upon the locality and extent 
of the syphilitic lesion. 

The prognosis is favorable if the disease is treated early and energeti- 
cally. 

Treatment. — Use mercury in the primary and secondary stages, and 
the iodides and mercury in the tertiary stage (see Syphilis). 
Tuberculosis of the Skin. 

Lupus Vulgaris. — Minute soft papules like apple jelly form mostly 
upon the face, nose, cheeks, and ears, developing gradually into nodules 
or tubercles which coalesce and form dull red, raised, soft patches. It 
develops usually before puberty. There is little or no pain. The patches 
may disappear by absorption, leaving a scarred, scaly, and atrophic skin 
(lupus ezfoliativus) , or may ulcerate and leave crusts and cicatrices (lupus 
exedens, exulcerans) , and if the crusts are removed, the base is found covered 
by granulations and bleeding freely; or exuberant granulations may appear 
upon the borders of the ulcers (lupus hypertrophicus) , or, again, the patches 
may develop in papillomatous outgrowths (lupus papillomatosus) . 

The prognosis is favorable. 

Treatment. — Use the actual cautery, tuberculin, x rays, Finnsen light, 
and radium. 

Miliary Tuberculosis. — The lesions are situated at the junction of 
mucous membrane and skin, at the entrance of the mouth, nose, vagina, 
and anus. There appear shallow ulcers with jagged, indented, "gnawed 
out " edges; the floor is covered by a viscid secretion and at times studded 
with yellowish elevations, miliary tubercles. It is extremely painful. It 
is usually associated with tuberculous disease of the internal organs. 

The prognosis is uncertain. 

Treatment. — Hygienic management and cauterization with glacial acetic 
or trichloracetic acid should be employed. 

Scrofuloderma. — At the outset the lesions appear usually on the face 
and neck as soft circumscribed infiltrations of the deeper tissues, over which 
the skin is freely movable; later the skin becomes involved, being hypersemic 
or bluish in color; the nodules soften and break down, forming ulcers with 
undermined edges, a soft bleeding floor, and fistulous tracts. Secondary 
infection occurs. The lesions are in the beginning neither tender nor painful. 

The prognosis is uncertain. 

Treatment. — Attend to the general hygiene, and use local cleanliness 
and camphor ice, iodide of potassium, if syphilis is suspected as the under- 
lying cause. Iron or arsenic in anaemic children. 



NEOPLASMS; NEW GROWTHS 



789 



Tuberculosis Verrucosa (Anatomical Wart). — This is due to direct 
local tuberculous infection (dissecting room infection). 

Inflammatory. — A growing plaque forms, covered with crusts in the 
centre, surrounded by a zone of pustules and this again by a bright ery- 
thematous zone. Between the warty excrescences there are fissures from 
which pus may be squeezed out. 

N on-Inflammatory . — There is a soft tubercle with a tendency to papillary 
hypertrophy of its surface; the pustular and erythematous zones are 
wanting. 

Both varieties affect mostly the hands or other exposed portions of the 
body. 

The prognosis is favorable. The warts rarely ulcerate, but may dis- 
appear by absorption. 

Treatment. — Employ incision, cauterization, Peruvian balsam, and a 
bichloride of mercury lotion (see formulary). 

Yaws (Framboesia). — This is a tropical contagious disease of the skin 
characterized by dirty or bright red raspberrylike tubercles which appear 
usually upon the face, toes, and genitalia. It is most frequently seen in 
young colored persons. 

The prognosis is unfavorable and the course is very chronic. 

Treatment. — Resort to incision, cauterization, Peruvian balsam, and a 
bichloride of mercury lotion (see formulary). 

NEOPLASMS; NEW GROWTHS 

I. BENIGN 

Adenoma Sebaceum. — There are small, round, convex tumors, from a 
pin's point to a split pea in size, reddish, brown, waxy, or normal in color, 
occurring mostly on the face, on either side of the nose, associated with a 
coarse skin and comedos. 

Angeioma (Vascular Tumor). 

Angeioma, Simple. — A small, violet or red, slightly elevated tumor 
appears usually on the face or neck, but also on other portions of the body. 
It is often congenital. The treatment is by excision or the actual cautery. 

Angeioma cavernous is a soft, doughy, non-pulsating tumor, leaden 
or blue in color, situated mostly near a mucous surface. 

The treatment is surgical. Excision or actual cautery. 

Angeioma telangiectatic has its surface often covered with small 
granular elevations resembling a strawberry, varying in size from that of a 
millet seed to several inches in extent. 

The treatment is by excision or the actual cautery. 

Angiokeratoma. — Warty growths occur over dilated vessels, usually 
on the dorsal surfaces of the fingers and toes. They are worse during cold 
weather and sometimes bleed freely. There may be successive attacks of 
chilblains. 

The treatment is by excision or the actual cautery. 

Cicatrix (Scar). — Flat, or Normal. — Situated at about the level of the 
normal skin. 



790 



DERMATOLOGICAL MEMORANDA 



Atrophic. — Lies below the skin's level in the form of contracted depressed 
areas. 

Hypertrophic. — Projects above the surface; may be elongated, rounded, 
star-shaped, or in the form of a network. 
The treatment is by excision. 

Clavus (Corn). — This is a local induration and thickening of the skin 
from pressure and friction. It is usually found on the dorsal surfaces of 
the phalanges, on the outer surfaces of the little toes, and also between the 
toes ("soft" corn). 

Treatment. — Soften the corn in hot soap suds, trim the hypertrophied 
layer, and apply glacial acetic or nitric acid. Formula No. 31. 

Bunion. — This is a swelling formed by an enlarged, thickened, and 
inflamed bursa and skin over the inner side of the metatarsophalangeal 
joint of the great toe, mostly due to the constant wearing of short and narrow 
pointed shoes. 

Treatment. — Insistence upon the patient's wearing a shoe with rounded 
toes, with a cotton pledget between the first and second toes, or draw- 
ing the phalanx inward by strapping or some mechanical device to avoid 
pressure. 

To subdue inflammation, rest, elevation of the foot, and the application 
of cold lead lotion or hot foot baths are to be employed. The indurated 
cuticle may be trimmed down with a sharp knife. 

Suppuration and ulceration may necessitate incision, curettage, and 
osteotomy of the head of the bone or thorough removal of the inner condyle. 
Examine with the x rays. 

Cystoma, Sebaceous. — This is a tumor of various size, firm or soft, 
round (if the sebaceous duct is obliterated) or flat (if the duct is open). 
It may be single or multiple, and is freely movable under the skin. The 
skin is normal or white, but red if inflamed. The scalp, face, back, and 
scrotum are favorite localities. 

Hydrocystoma (Cyst of the Sweat Glands). — The tumor consists of tense, 
transparent, shining, obtuse, round or oval vesicles, from a pinhead to a 
pea in size, usually on the face of middle aged women who perspire freely 
and are exposed to heat, especially laundresses. It is a disease of the 
summer and disappears in the winter. The vesicles dry up without rup- 
turing. 

Fibroma (hyperplasia of the connective tissue, the fibrous portion pre- 
dominating). 

Fibroma, Simple. — A hard tumor, usually single, appears upon the trunk 
or one of the extremities, either sharply defined or merging gradually into 
the normal tissue, and movable with the skin. 

The treatment is surgical. 

Fibroma Molluscum. — Multiple indolent tumors form, either buried 
in the skin or projecting and pedunculated, variously colored, rounded, 
flattened, or pulled out, often capable of invagination, so that the 
sensation of dipping into a pouch is received by the examining finger. 
They occur mostly on the anterior portion of the trunk, also on the 
head, etc. 

The treatment is surgical. 



NEOPLASMS; NEW GROWTHS 



791 



Keloid. — This is a scarlike fibrous tumor, movable with the skin, arising 
from preexisting scar tissue or an inflammatory exudation. It is single 
or multiple. It occurs mostly on the sternal region, and the growths are 
arranged in parallel rows if they are multiple. The tumor appears elevated, 
sharply bounded, or flat and cake-shaped; either firm or elastic, glistening 
white or red. The surface is smooth and usually without hairs. It is 
painful on pressure. 

The treatment is surgical. 

Lipoma (Fatty Tumor). — This is a soft, lobulated, circumscribed or 
diffuse tumor of varying size, surrounded by a loosely attached separate 
capsule, mostly on the neck, back, and nates. 

Treatment. — Removal if it is indicated. 

Lupus Erythematosus. — This takes the form of one or more rounded or 
oval spots, gradually increasing in size, either peripherally or by coalescence, 
from that of a small coin to that of the palm of the hand. The spots are 
sharply marginate and reddish or violaceous in color. The surface is covered 
by grayish or yellowish scales. The border is somewhat elevated and the 
central portion depressed. There is whitish atrophic scarring, with some 
itching and burning. It occurs mostly on the face. Its course is very 
chronic. Occasionally it undergoes involution. 

Treatment. — In the early stages: Formula No. 1, 4, or 15. In the 
later stages: Glacial acetic acid every other day until three applications are 
made and until the affected skin is thoroughly destroyed. Then use 
formulae Nos. 15 and 21. 

Lymphangeioma. — Small deeply seated vesicles appear in closely aggre- 
gated clusters. The epidermis covering them is firm and warty. The 
vesicles, if pricked, exude a clear, colorless liquid, lymph. There is a 
tendency to recurrent inflammation. 

The treatment is surgical if any. 

Myoma (Tumor composed of newly formed muscle tissue), single or 
multiple. 

Treatment. — Removal if indicated. 

Neuroma (Tumor Composed of Nerve Tissue). Several small tumors 
occur along nerve trunks or scattered over the body. 
Treatment. — Removal if indicated. 
Naevus (Birth Mark, Mole). 

NjEvtjs Pigmentosum. — This is usually congenital and characterized by 
a pigmentary deposit, with or without hypertrophy of the skin. 

N^vus spillus is smooth, flat, pigmented, and devoid of hair. 

NAEVUS pilosus is like the last mentioned variety, but covered with hair. 

N^vus verrucosus has an irregular or wartlike surface. 

NiEvus lipomatosus is elevated, with connective tissue and fat hyper- 
trophy. 

Naevus vasculosus is either congenital or developing soon after birth. 
It is due to dilatation and new growth of the cutaneous capillaries. They 
become pale or disappear on firm pressure. 

NjEvus flammeus (Port Wine Mark) appears on one side of face or 
on other parts of the body. There are diffuse, flat or slightly raised patches, 
bright red in color. The surface is smooth or irregular. 
51 



792 



DERMATOLOGICAL MEMORANDA 



NjEVUs Araneus (Spider Cancer) shows a small central red point, 
with projecting dilated vessels on all sides, like a star. 

NjEVUS Cavernosus. — There are prominent tumors of varying size, 
smooth or lobulated, sometimes pulsatile, soft, and easily compressible. 

Treatment of N^evus. — The actual cautery, excision, and electro- 
lysis. 

The apparatus necessary for electrolysis consists of a number of galvanic 
cells and a galvanometer. To the positive pole are attached a number of 
gold or platinum needles. The negative electrode is a large metal plate 
covered with chamois skin, which is placed near the field of operation. The 
current is applied slowly, and the needles may be introduced to any desired 
depth, about one inch apart. From 10 to 30 milliamperes are used. 
After the operation a moist antiseptic dressing is applied. The sittings are 
repeated once a week or once in two weeks. 

Papilloma (Hypertrophied Papillae of the Skin). — It is hard if on the skin, 
and soft if on a mucous membrane. It usually consists of secondary out- 
growths from some chronic inflammatory affection where the granulations 
have become hypertrophied and vegetating. 

Treatment. — Removal if indicated. 

Verruca (Wart). 

Verruca vulgaris occurs mostly in children, upon the head, face, 
hands, and ears, and is single or multiple. There are small, hard, sessile, 
conical elevations, with a flat top. It seems to be contagious and autoin- 
oculable. It may disappear spontaneously. 

Verruca Plana. — The lesions are smaller than in verruca vulgaris, 
but greater in number. It may be situated on any portion of the body. 
The warts are often grouped on the cheeks and forehead. It occurs mostly 
in young persons. 

Verruca senilis usually occurs in persons over fifty years of age, on the 
back, arms, face, neck, and trunk. The warts are often of a greasy con- 
sistence and the seat of pruritus, and may end in epithelioma. 

Verruca Filiformis. — There are small threadlike growths, mostly on 
the eyelids, neck, and chest, in adults. 

Verruca digitata is characterized by small threadlike growths sepa- 
rated at the base, multiple, occurring on the scalp, etc. 

Verruca Acuminata. — The lesions are closely aggregated, sessile or 
pedunculated, and may resemble mulberries; they occur mostly on the 
genitalia. In pregnant women they are apt to increase rapidly and then 
disappear spontaneously after parturition. 

Verruca syphilitica (condyloma) is mostly a secondary symptom of 
syphilis, but may also play the part of primary syphilis. It may affect 
exposed situations or occupy some cleft. In the one case it will be an ashy 
gray, dry wart, hard and rasplike to the touch; in the other, composed of 
semitransparent, pink, moist, ill smelling fungous granulations. It may 
be sessile or pedunculated. 

Treatment. — Removal by ligature, excision, or different caustics. 
Take 15 grains of corrosive sublimate and dissolve in 1 ounce of collodion. 
Brush the warts carefully once a day with this solution. Also specific con- 
stitutional treatment. 



MALIGNANT NEOPLASMS 



793 



Xanthoma. 

Xanthoma Planum. — There are flat, sharply bounded, soft patches or 
plates, of a dull yellow color, usually on the eyelids. 

Xanthoma Tuberosum. — There are raised soft nodules, in size from 
that of a pea to that of a small orange, on the extensor surfaces of the limbs, 
fingers, toes, knees, palms, and soles. At times it involves mucous mem- 
branes. It is of a dull yellow color, at times associated with jaundice. 

Xanthoma Diabeticorum. — There are firm raised nodules, round or 
oval, chiefly red, with the apex yellow, associated with diabetes mellitus. 
It is of rapid development and often undergoes involution without leaving 
scars. 

Treatment. — Removal if necessary. 

MALIGNANT NEOPLASMS 
Carcinoma Cutis (Epithelioma). 

Carcinoma lenticulare is usually secondary near a cancerous cica- 
trix. There are white or reddish papules, with a smooth glistening surface. 
It advances by gradual growth and infiltration and often ends in ulcera- 
tion. Metastasis and cachexia occur. 

Carcinoma tuberosum may be either primary or secondary. There 
are firm papules, nodules, and tubercles, deeply seated, discrete, or confluent. 
Ulceration and metastasis occur. 

Carcinoma pigmentosum arises from moles, forming hard and soft 
elastic nodules of different colors. They may remain stationary for some 
time, or metastasis may take place to internal organs, with rapid maras- 
mus and death. 

Epithelioma (Epithelial Cancer, Rodent Ulcer). — This occurs mostly on 
the face, lower lip, tongue, eyelids, and genitalia. 

Epithelioma Superficiale (Discoid). — There are flat, yellowish or 
reddish patches, with a tendency to excoriation and crusting. After months 
or years the lesions increase in number and there is a formation of round 
ulcers with sharply indurated, pearly edges and hard, uneven, bleeding 
base, secreting a scanty yellowish fluid. There is slight pain, but there are 
no constitutional symptoms. 

Epithelioma, deep seated (nodular), may occur secondarily to the 
superficial form or primarily, beginning with a firm, indurated, shiny 
reddish or purplish nodule, varying in size from that of a pea to that of a 
walnut, terminating within a few months in a deep, uneven ulcer with an 
easily bleeding base and hard, everted, purplish edges. There is severe pain, 
with constitutional symptoms. 

Epithelioma (papillary) may follow the other varieties or develop 
from an ordinary wart; it may appear as a small verrucous elevation or as 
a large, lobulated, spongy, papillary growth. The surface is dry or moist 
and covered with exuberant granulations. Disintegration occurs, with the 
formation of fissures and ulcers. 

Treatment of Epithelioma and Carcinoma. — Excision or by caustics. 
Exposure to x rays, Finnsen light, radium. Formula? Nos. 40 and 41. 

The use of caustics in the radical treatment of carcinoma has a lim- 



794 



DERMATOLOGICAL MEMORANDA 



ited field of usefulness. Cutaneous cancers are usually treated more sat- 
isfactorily by escharotics than by any other method. Caustic agents 
should be applied in such a manner as to produce the requisite effects 
by a single application, otherwise the irritation gives, not necessarily, but 
commonly, new activity to the disease. 

Mycosis Fungoides (Granuloma Fungoides). — First Stage. — There are 
rounded, oval or crescentic, sharply bounded patches, bright red in color, 
on the trunk, limbs, and face. It resembles eczema, erythema, or urticaria. 
Severe itching may come and go for a period of years before the disease 
reaches the second stage, which is characterized by infiltration of the plaques, 
a new development of papules, and hard round, pale nodules. It may 
persist or disappear and leave pigmentation or superficial atrophy. Third 
stage : There is the development of red, violaceous, shining tumors re- 
sembling tomatoes of various sizes. It may either follow the first or second 
stage or appear suddenly. It may disappear spontaneously or ulcerate, 
break down, and cause marasmus and death. There is usually no involve- 
ment of the glandular system. 

The treatment is hygienic, surgical, and by cauterization. 

Paget's Disease of the Nipple. — This occurs mostly in women between 
forty and fifty years old. It begins as an inflammation of the skin of the 
nipple and areola of one breast, resembling eczema. The surface of the 
plaque is bright red, circinate, oozing in places, or covered with crusts and 
scales; later on, irregular, confluent, dry, glazed islets of epidermis are seen 
scattered over the excoriated surface. There are induration and retraction 
of the nipple, with pain and itching. The duration is from two to seven 
years. 

The treatment is surgical. 

Sarcoma. — Sarcoma, primary, non-pigmented, single, develops at the 
site of a cicatrix or naevus or in or beneath normal skin. It may remain 
stationary for years, then enlarge and infiltrate the skin and internal organs, 
and produce general sarcomatosis. It differs from carcinoma in its softer 
consistence and its greater tendency to assume a peculiar configuration, 
such as toadstool and pedunculated forms. 

Sarcoma, general cutaneous, may follow the primary variety or 
sarcoma of the internal organs and affect the whole integument. It may 
end fatally very rapidly. 

Sarcoma, melanotic, may be primary on the skin or secondary to a 
tumor of an internal organ. The starting point is a pigmented naevus or 
other pigmented lesion, such, for instance, as chloasma or a stain of purpura. 
The tumor is rounded, nodular, brownish or black, and varying in size and 
consistence. It is very malignant and rapidly fatal. 

Sarcoma, Multiple, Idiopathic, Pigmented. — This usually begins 
on the hand or foot, rapidly advancing upward upon the arm or leg to the 
trunk and face. The tumor is firm, reddish brown or purple, as large as a 
pea or a bean; it may undergo partial or complete involution, leaving a 
pigmented cicatrix. The internal organs, especially the descending colon 
and very rarely the lymphatic glands, may become affected. The mucous 



SENSORY DERMATONEUROSES 



795 



membranes are involved in the latest stages, when fever, haemorrhage, and 
marasmus precede the fatal termination. 

The treatment is the same as for carcinoma. Injections of Coley's 
toxines or formalin water may be used 1 = 1000. 

DERMATONEUROSES 

SENSORY DERMATONEUROSES 

Dermatalgia. — Idiopathic pain of the skin. 
Hyperassthesia. — Exaggeration of the cutaneous sensibility. 
Tactile Anaesthesia. — Insensibility of the skin to touch. 
Thermoanaesthesia. — Insensibility of the skin to heat. 
Analgesia. — Insensibility of the skin to pain. 
Dysaesthesia. — Hyperaesthesia with some disagreeable sensation. 
Allochiria. — Confusion as to which side is the subject of a sensory im- 
pression. 

Error of Place. — Impossibility to locate the exact spot of excitation. 

Delayed Sensation. — Unconsciousness of sensation for several seconds. 
The sensory dermatoneuroses just enumerated are usually associated with 
either functional or organic nervous derangements, and must be treated in 
accordance with their aetiological factors. 

Pruritus. — This is severe itching without, primarily at least, any appreci- 
able lesion of the skin. It is worse at night, and as a result of scratching 
there are excoriations, papules, etc. It may be local or general, and is 
often dependent upon constitutional disturbances, such as diabetes. The 
regions commonly affected are the anus (pruritus ani, often caused by 
haemorrhoids, anal fissures, or fistulas), the vulva (pruritus vulvae may be due 
to vaginal or uterine discharges), and the scrotum. Pruritus is often met 
with in old people (pruritus senilis), and in some cases it makes its appear- 
ance only during the cold season of the year (pruritus hiemalis) . The latter 
variety affects mostly the extensor surfaces of the lower limbs. 

The Treatment of Pruritus. — (1) Local anaesthetics: Refrigeration, 
cocaine, orthoform, menthol, chloral, camphor, phenol, resorcin, sulpho- 
phenate, guaiacol, salicylate of methyl. (2) Medicines causing a substi- 
tutive reaction: the local anaesthetics given above; alcohol, vinegar, 
chloroform, tincture of iodine, essence of turpentine, hot and dry air. (3) 
Antiphlogistics: local vasoconstrictors, cocaine, adrenalin, hot water. (4) 
Agents affecting the integuments: nitrate of silver, picric acid, tannin. 
(5) Topical anodynes preserving the skin from irritation: lime and oil lini- 
ments, glycerinated lime water, oil, vaselin, lanoline, traumaticin, collodion. 
Attention must be paid to the underlying cause, such as dyspepsia, anae- 
mia, neurasthenia, etc., with local cauterization of fissures and ulcers and 
brushing the itching parts with a hair brush. The surgical treatment of 
pruritus vulvae is by resection of the genitocrural, ilioinguinal, inferior 
pudendal, and superficial perineal nerves. 



796 



DERMATOLOGICAL MEMORANDA 



MOTOR DERMATONEUROSES 

Cutis Anserina (Goose Skin). — There is erection of the hair follicles 
under the form of small miliary projections, due to nervous excitation of 
the muscular fibres of the skin. 

TROPHIC DERMATONEUROSES 

Acrodynic Erythema (Erythromelalgia) . — Erythematous brownish spots 
form, mostly on the palms of the hands and the soles of the feet, sometimes 
accompanied by oedema, ecchymosis, cyanosis, or even partial gangrene. 
It is due to a toxic cause acting upon the nervous system, especially the 
spinal cord. There are often numbness, pricking, tingling, and lancinating 
pain. 

The treatment is tonic and hygienic, directed to the underlying cause. 

CHRONIC TROPHONEUROTIC ERYTHEMA 

Glossy Skin (Atrophoderma). — The skin is smooth and shining in a diffuse 
or mottled manner, pink or red in color, and often appears as if varnished. 
The disease affects mostly the extremities, especially the hands and feet. 
There are neuralgic pains, with gradual thinning of the skin and later also 
of the muscles. It usually follows an injury to nerves. The duration is 
from weeks to years. 

The treatment is directed to any underlying cause. 

VASCULAR DERMATONEUROSES 

Anaemia (pallor) and hyperaemia (blushing) are examples of this neurosis ; 
to this class belongs also: 

Raynaud's disease, or sphaceloderma, which is observed in three well 
defined degrees. Pain is the most prominent symptom. 

1. Local syncope occurs mostly in the extremities, and produces a con- 
dition known as "dead fingers or toes." 

2. Local asphyxia affects usually the fingers, toes, and ears, and generally 
follows local syncope, but may also appear independently. If severe, it is 
accompanied by stiffness, swelling, and lividity of the affected parts. 

3. Local, or Symmetrical, Gangrene. — Small areas of necrosis appear on 
the pads of the fingers and toes, also at the edges of the ears and tip of the 
nose. 

The prognosis depends on the underlying cause. 
The treatment is directed to the underlying cause. 

MAL PERFORANS (PERFORATING ULCER OF THE FOOT) 

This is observed in severe constitutional disease. 

The treatment is local (antiseptic dressing) and constitutional. 



THE HAIR AND NAILS 



797 



DISEASES OF THE APPENDAGES 

THE HAIR 

Atrophy of the Hair; Alopecia (Baldness) 

Alopecia, Primary or Parasitic. — This variety includes the affection 
known as alopecia areata, which involves usually the scalp and more rarely 
the beard, eyebrows, eyelashes, etc. It begins with one or two rounded 
circumscribed patches; the skin is smooth, soft, and of a dead white color; 
it may develop suddenly or gradually and spreads peripherally, at times 
affecting the whole scalp. To this class belongs also the baldness due to 
tinea trichophytina, tinea favosa, and the different forms of folliculitis. 

Treatment. — Formula? Nos. 30 and 46. 

Alopecia, Secondary or Non-Parasitic. — Under this head are classed the 
cases due to nutritional changes. It is usually associated with senility, 
syphilis, and myxcedema, or follows acute infectious diseases, typhoid 
fever, trauma, or severe neuralgia. It may also be congenital (hypotri- 
chosis congenita). 

The prognosis is good in the primary, bad in the secondary, forms, 
except those following acute infectious diseases. 

Treatment. — Removal of the cause and the use of tonics internally. 
Formula No. 27. 

Hypertrophy of the Hair 

Hypertrichosis (Hirsuties). — This is an abnormal growth of hair, involv- 
ing either a greater part of the body or only the face, neck, arms, bust, etc. 

Treatment. — Calcium sulphide applied locally and electrolysis (see 
Naevus), 10 to 30 milliamperes. 

Canities (grayness of the hair) is due to absence or diminution of pig- 
ment, the presence of bullae between the hair fibrillar, or both causes. 

Canities, congenital, may be partial or general. One or more tufts 
of silvery or yellowish white hair may appear in the scalp. 

Canities, acquired, may be caused by neuralgia, erysipelas, perhaps 
also fear and emotion and unknown causes. 

Treatment. — Order the hair wash, formula No. 47. The hair may be 
dyed if it must be. 

THE NAILS 

Onychia is inflammation of the matrix of the nail. There are pain, 
redness, and ulceration of the matrix; the nail soon rots and crumbles away 
at the root. It is usually due to injury of the overlying skin with secondary 
infection. 

Treatment. — A moist antiseptic dressing or removal of the nail may be 
employed. 

Onychatrophia. — This is characterized by shedding, crumbling, and 
deformity of the nails, and is associated with different diseases, such as 
eczema (the skin about the nail becomes reddened, thickened, and the seat 
of considerable itching ; there is a lack of natural polish and lustre) ; psoriasis 



798 



DERMATOLOGICAL MEMORANDA 



(dirty yellowish discoloration and loss of polish of the nails, which may be 
broken, pitted, and furrowed); or tinea trichophytina ("onychomycosis"), 
in which the nail is at first yellowish, dirty, and friable at its free extremity, 
and later streaked with yellow, loosened from its seat, and hypertrophied. 

Treatment. — Pay attention to the underlying cause. 

Onychogryphosis. — There are thickening and deformity of the nail plate 
itself or deformity and distortion caused by a heaping up of the epithelium 
of the nail bed under the nail plate. 

Treatment. — Manicure. 

Ingrowing nail occurs mostly on the great toe, occasionally also on the 
fingers. It is usually a result of wearing tight boots. 

Treatment. — Bathe the parts in hot soap suds until the nail and sur- 
rounding skin are softened. Separate the nail from the injured skin and 
instill pure carbolic acid between them, followed by neutralization with 
alcohol. After repeating this process for a few days, raise and trim the 
ingrown nail and keep the parts free from dirt and pressure. If it is very 
obstinate, surgical interference may be required. 

FORMULARY 



1. Acidi salicyl., gr. xv-xx; 

Acidi carbol., gtt. xij; 

Ung. hydrarg. amnion., 3ij; 

Ung. zinci oxidi, ad, 5j- 

M.: For parasitic skin lesions. 

2. 1$ Olei cadini (oil of cade), 3j; 

Ung. zinci oxidi, ad, §j. 

M.: For chronic forms of eczema. 

3. fy Plumbi acetici., Sss. ; 

Pulv. camphorse, gr. xv; 

Olei amygdal., 3ij; 

Cerati flav., 5j- 

M.: F. ungt. For wet eczema. 

4. Py Sulphuris prsecipit., 3j-3ij; 

Resorcini, gr. x; 

Acetanilidi, 3ss.; 

Ung. petrol., 5j- 

M. : In parasitic varieties. 

5. 1$ Acidi carbol., gtt. xv; 

Pulv. camphorse, gr. x; 

Alcoholis, 3ij,* 

Glycerini, 3ij; 

Olei amygdal., ad, 5j- 

M. : To relieve itching. 



FORMULARY 799 

6. B; Acidi salicyl., 5ss. ; 

Resorcini, gr. xx; 

Alcoholis, Bjss. ; 

Olei ricini, ad, Sij- 

M.: In eczema or parasitic affections of the head (tinea favosa). 

(H. B. Sheffield). 

7. I* Amyli, Sij; 

Acidi borici, 3ss. ; 

Cocainae, gr. jv; 

Ung. zinci oxidi, ad, 5j- 

M. : In acute cases with severe itching. 

8. R Sulphuris praecip., 5j-5ij; 

Pulv. camphorae, gr. x; 

Pulv. tragacanthae, 3ss.; 

Alcoholis, 5ij; 

Aquas calcis, 5j; 

Aquas rosae, ad, gij. 

M. 

9. B; Hydrarg. chlor. corrosiv., gr. iij; 

Acidi hydrochlor. dil., : 3j; 

Alcoholis, 3j; 

Glycerini, 5ss.; 

Aquae, . . . .ad, gjv. 



M. : Apply at bed time, and remove with sugar water in the 
morning. 

10. R Hydrarg. chlor. corros., 

Acidi acetic, dil., 

Boracis, 

Aquae rosae, 

M.: Apply twice daily. 



11. R Acidi salicyl., gr. x; 

Zinci oleatis, 3 j. 

M.: S. dusting powder. 

12. R Acidi salicyl., gr. xv; 

Cretae praep., 5ss.; 

Aluminis exsic, ad, 5j- 

M. : Mix and powder finely. 

13. R Acidi borici, 5ss. ; 

Pulv. camphorae, gr. x; 

Bismuth subgal., gr. x; 

Talci, 5jv; 

Zinci oxidi, ad, Bj- 

M.: S. dusting powder. 



gr-vj ; 
oij; 
gr. xl; 



DERMATOLOGICAL MEMORANDA 

14. 1$ Stearate of zinc with acetanilide. 
Sig. dusting powder. 

15. 1$ Sulphuris prsecip., 3ij; 

Beta naphthol, 3ss.; 

Ung. petrolati, Bj- 

M. : To relieve itching in chronic affections, tar may be added. 

16. Py Chrysarobin., gr. xv; 

Ung. petrolati, Bj- 

M. 

17. Py Hydrarg. chlor. mitis, gr. xv; 

Pulv. tragacanth., Bj- 

M.: Dusting powder in herpes. 

18. Hydrarg. chlor. mitis, gr. x; 

Acid, salicylic, gr. xv; 

Pulv. tragacanth, 3ij; 

Pulv. amyli, ad, Bj- 

M.: Sig. dusting powder. 

19. Py Balsami peruv., 3ij; 

Sulph. prsecip., 3ij; 

Acidi salicyl., 3ss.; 

Ung. petrolati, Bij- 

M.: In scabies it is preceded by scrubbing with sapo viridis. 



20. Py Ung. hydrarg. nitr., 
Ung. sulphuris, 

M. 



aa, 3jv. 



21. R, Ichthyolis, 3j; 

Ung. zinci oxidi, Bj- 

M. 

22. P, Ung. hydrarg., 3vj; 

Ung. belladonna?, ad, Bj- 

M.: In itch or in syphilitic bubo. 

23. R, Bismuth subcarb., Bij; 

Ung. zinci, Bj- 

M.: S. for facial eczema. 

24. Sulph. praecipit., 3ij; 

Ung. zinci oxidi, 3jv; 

Terras silicicse, ad, Bj- 

M. 



FORMULARY 



801 



25. R; Resorcini, 3j; 

Glycerini, 5ss.; 

Aq. aurant. flav., 5jv; 

Alcoholis, ad, gj. 

M. 

26. R Ichthyol, 3j; 

Aquae, gj. 

M.: For intertrigo. 



27. R Sulphuris prsecip., 5ij; 

Pulv. camphorae. gr. x; 

Tr. cantharidis, 3ij; 

Resorcini, gr. xx; 

Olei myrciae, gtt. x; 

Alcoholis, ad, gij. 

M. 



(H. B. Sheffield.) 



28. R Acetanilidi, 5ss. 

Olei amygdalae am., 5ij; 

Ung. aquae rosae, ad, 5j- 

M. 



29. R Acidi carbol., ) __ 

Olei petrolei, } aa ' 3lj; 

Tinct. iodini, ) _ _ 

' } aa, 5111SS. ; 

Olei ricim, ) ' J ' 

Olei rusci (German), ad, Oj. 

M. : After clipping the hair close to the scalp this mixture is applied 

over the entire scalp — more thickly over the affected spots — by means of a 

painter's brush, once a day for five successive days. On the sixth day it is 

wiped off with a rag dipped in plain olive oil ; now the hair is clipped again 

and the scalp washed thoroughly but gently with green soap and a soft 

nail brush, care being taken that all the scales and loose hair covering the 

scalp are removed. No epilation is, as a rule, necessary. On the seventh 

day the mixture is reapplied as thickly as before and the whole process 

is repeated regularly for three or four successive weeks — the length of time 

depending upon the severity of the case — when it is found that new hair 

begins to appear and no trichophyton fungi can be discovered in the hair 

extracted for microscopical examination. 

These procedures are followed by a few days' application of a 10 per 

cent sulphur ointment. (H. B. Sheffield.) 



30. R Chrysarobin ointment, 20 to 30 grains to the ounce. 



802 



DERMATOLOGICAL MEMORANDA 



LOCAL APPLICATION FOR CORNS 



31. 1$ Salicylic acid, 15 grains; 

Extract of cannabis indica, 7h grains; 

Alcohol, 90 per cent, 16 minims; 

Ether, 62 per cent, 37 minims; 

Flexible collodion, .' 80 minims. 



M.: To be applied every evening for eight days. On the eighth 
day a prolonged foot bath should be taken, then with a scraper the mass 
of collodion, with the greater part if not all of the corn, may be removed. 
This treatment may be repeated if necessary. 



32. ~Bp Pulv. camphorae, 5ss.; 

Aquae amnion., 5j; 

Ext. hamamelis, ad, §iij. 

M. 



33. Py Phenic acid, gr. xv; 

Salicylic acid, 3ss.; 

Tartaric acid, gr. xlv; 

Glycerole of starch, gij. 

M. (Brocq.) 

34. Py Pyrogallic acid, 3iss.; 

Salicylic acid, gr. xxx; 

Pure vaseline, 5ij- 

M. (Brocq.) 



35. fy Liq. plumbi subacet. dil. (1-20), ) __ - ... 

Aquae rosae, ) '" ' ' ° V11 J" 

M. 

36. Py Ung. zinci oxidi, 
M 



Ung. aq. rosae, j 



37. Py Balsami peruviani, 5j; 

Resorcini, gr. x; 

Ung. aquae rosae, §j. 

M. 

38. Py Acidi salicyl., gr. xv; 

Sulphuris praecip., 3j; 

Pulv. camphor., gr. x; 

Alcoholis, Sjss. ; 

Olei ricini, 5j- 

M. 

39. R Cerati resinae comp., 5vij; 

Olei olivar., ad, 3j- 

M. 



FORMULARY 



803 



bougard's caustic compound for cancer 



40. Py Wheat flour, oij; 

Starch, 5ij; 

Arsenic, gr. xv; 

Cinnabar, 5j; 

Sal ammoniac, 5j; 

Corrosive sublimate, gr. j; 

Saturated solution of chloride of zinc, Sviij. 

M. 

41. J\ Arsenous acid, 1 part; 

Cocaine hydrochloride, 5 parts; 

Boiled distilled water, 500 parts. 



M.: One to 2 c.c. (16 to 32 min.) of this liquid are injected into 
the neoplasm at intervals of from two days to a week. 



SUN BURN LOTION 

42. Acidi citrici, . oij; 

Ferri sulphatis puri, gr. xviii; 

Camphorae, q. s.; 

Aq. flor. sambuc, Siij. 

M.: The camphor is placed in the bottle in a lump, undissolved. 

HYDROQUINONE WASH FOR THE SKIN 

43. Py Hydroquinone, gr. xlviii; 

Acid, phosphoric, glac, gr. xxx; 

Glycerini, 3ij; 

Aquae dest., 5vj. 

M. 

"albadermiNe" 

Under this empirical title, a foreign surgeon has devised the following 
process of removing "tan" and the milder variety of "freckles": 

solution "a" 

44. B Potass, iodid., 5ij; 

Iodi., gr ;. v j>" 

Glycerini, 3iij; 

Infus. rosse, 5jv. 

Dissolve the iodide of potassium in a small quantity of the infusion 
and a drachm of the glycerine; with this fluid moisten the iodine in a glass 
mortar and rub it down, gradually adding more liquid until complete solu- 
tion has been obtained; then stir in the remainder of the ingredients, and 
bottle the mixture. 



804 



DERMATOLOGICAL MEMORANDA 



SOLUTION "b" 

fy Sodii hyposulph., oss.; 

Aquse rosae, Oj. 

Dissolve and filter. 
With a small camel's hair pencil or piece of fine sponge apply a little 
of " Albadermine A" to the tanned or freckled surface until a slight but toler- 
ably uniform brownish yellow skin has been produced. At the expiration 
of fifteen or twenty minutes moisten a piece of cambric, lint, or soft rag with 
" B " and lay it upon the affected part, removing, squeezing away the liquid, 
soaking it afresh, and again applying until the iodine stain has disappeared. 
Repeat the entire process thrice daily, but diminish the frequency of the 
application if tenderness is produced. In the course of from three or four 
days to as many weeks either the freckles will have disappeared entirely, 
or their intensity will be very greatly diminished. " Summer freckles" yield 
very speedily to this treatment. 



ANTI-FRECKLE LOTION 

45. Hydrarg. bichlor., gr. xii; 

Acid, hydrochlor., dilut., 3iij; 

Fruct. amygd. amar., Sjss.; 

Glycerini, §j; 

Tinct. benzoin., 5ij; 

Aquse florum aurant., q. s. 



Dissolve the corrosive sublimate in three ounces of the orange flower 
water, add the hydrochloric acid, and set aside. Blanch the bitter al- 
monds, and bruise them in a mortar, adding thereto the glycerine and 
using the pestle vigorously; a smooth paste is thus obtained. Then add 
gradually about 9 ounces of the orange flower water, stirring constantly, 
continuing this operation until a fine, creamy emulsion is the result. Sub- 
ject this to violent agitation — preferably with the aid of a mechanical egg 
whisk — and allow the tincture of benzoin to fall into it the while drop by 
drop. Then add the mercurial solution, filter, and make up the whole to 
the measure of one imperial pint with more orange flower water. 

BISMUTH OINTMENT FOR FRECKLES 

B; Bismuthi subnitr., oij; 

Ung. simpl., ' gij. 

M. : Apply to the skin at night and remove in the morning with a 
little cold cream previous to washing. 

46. Shampoo with tar soap ten minutes, and wash and dry the scalp. 



Apply: 

Bi Hydrarg. bichlor., gr. vij; 

Glycerini, 3j; 

Aquae, 5 v. 



M. : After this add a half per cent solution of naphthol in 
absolute alcohol. Then apply: 



FORMULARY 



1^ Acid, salicyl., gr. xxx; 

Tinct. benzoin, 3j; 

01. olivar., giij. 

M.: Against parasitic alopecia. 

P»s Potass, carbon., ) __ _ 

Ammon. carbon.,} aa ' oss. , 

Glycerini, 5jv; 

Aquae, ) __ B ... 

c • • • > aa > ovni ; 

bpir. vim., ) ' 

01. lavandal, gtt. vj. 

M.: Hair wash. 

FOR PSORIASIS 

Py Acid, salic, 5ij; 

Chrysarobin., } __ 



Olei ruse, j aa ' 3J " 
Sapon. virid., ) - 
Vaselin., J aa ' dV ' 
M. : Apply twice daily for one week and repeat if necessary. 



CHAPTER XXIX 



OTIC MEMORANDA 

Synopsis : General Remarks. — Minor Local Ailments in or about the Ear. — Otitis Media, 
Acute and Chronic. — Mastoid Disease. — The Sense of Hearing. — Deafness and Aural 
Vertigo. — Diagnostic Value of Fluid Discharges from the Ear in Head Injuries. — 
Formulary. 

GENERAL REMARKS 

An examination of the external auditory canal is readily made by means 
of an ear speculum and reflected light, as shown in the illustration. Secre- 
tions, wax, and other debris frequently hide the drum membrane and should 
be removed by syringing or by means of a cotton carrier. 

Other necessary requisites for aural examinations are the Eustachian 
catheter, the Politzer inflation bag, and an auscultation tube. 

The color of the drum membrane under normal conditions is pearly 




Fig. 221. — Eustachian Catheters (Roosa). 



white. When an inflammation of the middle ear exists, the membrane is 
either pink or deeply reddened, and may be bulging. 

Perforation of the drumhead is visible or is detected by inflating the 
ear by means of Politzer's bag and listening for the hissing sound as the air 
is forced through the opening in the membrane. 

Hearing may be tested by means of the voice, watch, or tuning fork. 

Earache, deafness, tinnitus, and discharge are the principal symptoms of 
an inflammatory condition in or about the ear. Infection usually takes 
place from the nasopharynx and is generally secondary to the various 
forms of inflammation in this locality. Otitis media is therefore a fre- 
quent sequel to diphtheria, measles, scarlatina, amygdalitis, parotitis, 
influenza, typhoid fever, adenoids, and many other pathological conditions. 
In order to prevent, if possible, ear complications in the course of the ex- 
anthemata, the author advises the instillation of salt water (5j to pt. j) 
into the nostrils, £ teaspoonful at a time (see article on Nasopharyngeal 
Toilet). 

806 



MINOR LOCAL AILMENTS IN OR ABOUT THE EAR 807 



It is important to practise anterior and posterior rhinoscopy in connec- 
tion with ear work, and it is well to remember that we meet with reflex 
otalgia from dental irritation and with aural vertigo, faintness, and asthma. 

MINOR LOCAL AILMENTS IN OR ABOUT THE EAR 

External otitis from infection is generally traumatic and caused by over- 
cleanliness in using hairpins, toothpicks, or the finger nail for the purpose 
of cleansing the auditory canal. It is apt to affect the structures of the 




Fig. 222. — Examination of the Eak. 
The lamp should be placed to the right of patient. 



canal and the upper posterior region of the auricle. The parts become 
swollen and extremely painful and local periostitis develops, the middle ear 
remaining intact. This type of external ear disease has often been mis- 
taken and treated for mastoiditis. 
52 



808 



OTIC MEMORANDA 



Treatment. — Strict cleanliness and the repeated application of a 3 per 
cent acetate of aluminum solution are very effective in this condition. 
Dry heat in the form of a hot water bag will relieve the intense pain. In 
the event of fluctuation (pus formation), a free incision is to be made. 

Eczema of the auricle and external auditory canal presents symptoms 
identical with those observed in eczema of the skin of any other part of 
the body. 

For the treatment, see Eczema. 

Furuncles can readily be distinguished from deeper ear affections by 
careful inspection, and are best treated by hot fomentations and incision 
according to general surgical principles in regard to strict antisepsis. Quite 
an extensive infection may take place. 

Impacted cerumen gives rise to buzzing in the ear, deafness, and some- 
times vertigo. 

Treatment. — Syringing with warm water, preceded by filling the audi- 
tory canal with olive oil or peroxide of hydrogen. 

Foreign bodies, such as insects, beads, and buttons, are sometimes found 
in the external auditory canal, and may give rise to the symptoms enumer- 
ated under "impacted cerumen." They are best removed by syringing 
with warm water. Foreign bodies, such as peas or beans, which are apt to 
swell in water, should be removed by the blunt hook or forceps. Anaesthesia 
may be necessary, especially in children. 

Treatment. — A piece of soft rubber tube, of the length of a cigarette 
and of the proper size, is to be introduced into the ear. The end of the tube 
is dipped in paraffin and pushed into the canal until it comes in contact with 
the foreign body, whereupon the operator, applying his mouth to the free 
end, aspirates forcibly, at the same time throwing back his head. 

Malformations, wounds, tumors, cysts, erysipelas, frostbites in and about 
the ear present the same features as similar pathological conditions in other 
parts of the body and require the same management. 

Otitis media catarrhalis is caused by changes of temperature, so called 
colds, and bathing in cold water, but most frequently is due to diseases of 
the nasopharynx, adenoids, etc. It is manifested by pain, tinnitus, hard- 
ness of hearing, and dizziness. The tympanum is red and if considerable 
exudation is present there is bulging. This catarrh of the middle ear may 
terminate either in recovery without rupture or after rupture of the drum 
membrane and escape of the exudation, or in subacute or chronic catarrh. 

Treatment. — In the acute stage apply hot applications and leeches 
behind the ear to relieve pain, or, if the latter continues, paracentesis should 
be resorted to, followed by daily cleansing of the auditory canal with mild 
antiseptic solutions. In chronic cases Politzer's inflation method in ad- 
dition to cleanliness is to be practised. 

Acute otitis media purulenta may occur as a result of severe inflammation 
of the nasopharynx or in the course of various infectious and contagious 
diseases. Acute purulent inflammation of the middle ear resembles simple 
catarrhal inflammation, except that the symptoms are more pronounced. 
Perforation of the membrane takes place in the majority of cases and is 
followed by immediate relief from the pain and sense of fulness. The 
secretion is very profuse at first, but gradually ceases with the healing 



OTITIS MEDIA AND MASTOID DISEASE 



809 



of the perforation. This type of middle ear disease frequently leads to 
involvement of the mastoid, also to extradural abscess, perisinusitis, and 
meningitis. 

The treatment is the same as for catarrhal inflammation of the middle 
ear. The more severe cases require management in accordance with the 
complication present. 

Chronic purulent inflammation of the middle ear is characterized by a 
discharge which may be purulent or mucopurulent and sometimes tinged 
with blood; and by deafness, moderate or marked. The drum membrane 
is perforated or completely destroyed. There may be a formation of 
granulations and polypi, which are very apt to cause retention of pus; or 
caries and destruction of the ossicles. Caries of the attic and cholesteatoma 
constitute serious complications. Other serious complications and sequelae 
are: Mastoiditis (usually brought on by an exacerbation of chronic purulent 
inflammation of the middle ear), brain abscess, sinus thrombosis, caries of 
the carotid canal with rupture of the internal carotid artery, meningitis, 
pyaemia, facial paralysis, and extensive necrosis of the temporal and ad- 
jacent bones. 

Treatment. — Enforce scrupulous cleanliness, with attention to the 
nasopharynx (adenoids). In tuberculosis and syphilis, use constitutional 
treatment. Polypi should be removed by means of the snare or forceps. 
Granulations may also be destroyed by instilling pure alcohol, 5 to 10 drops, 
twice daily. If the discharge is profuse, irrigations with boric acid solution 
must be done once or twice a day before applying local treatment, i. e., 
with alcohol, etc. Carious ossicles must be removed. In case of caries of 
the attic and cholesteatoma, a radical operation is necessary to save life. 

MASTOID DISEASE 

Inflammation of the mastoid process of the temporal bone forms a 
frequent complication of suppuration of the middle ear. It is manifested 
by pain in the mastoid region and tenderness on deep pressure, fever, if the 
inflammation is acute, and swelling, redness, and heat as the disease ad- 
vances. If the inflammation invades the middle fossa of the skull, an abscess 
may be produced beneath the dura mater or abscess of the brain and men- 
ingitis may result or sinus thrombosis. 

Treatment. — Attention should be paid to the tympanic cavity by per- 
mitting the free exit of the pus and by keeping the auditory canal thoroughly 
clean. The inflammation should be reduced by ice applications or by means 
of Leiter's coils. If these means fail surgical interference is necessary. 

SENSE OF HEARING 

The sense of hearing is often affected in various ways. Nervous deafness 
is caused by lesions of the eighth, or auditory, nerve, of the cortical centres 
of hearing, or of the acoustic nuclei. Labyrinthine disease may cause deaf- 
ness, also drugs, such as quinine and the salicylates, inflammations, includ- 
ing syphilitic exudates, injuries, haemorrhages, and tumors, primary atrophy 
as occurring in locomotor ataxia, and mechanical causes, such as the constant 



810 OTIC MEMORANDA 

noises and jarring to which locomotive engineers and boiler makers are 

subject. 

Tinnitus aurium is a term applied to those subjective sounds which 
resemble hissing, buzzing, humming, beating, musical notes, etc. It may 
be caused by neurasthenic conditions, local ear disease, gastrointestinal 
toxaemia, reflex irritants, and arteriosclerosis. 

Vertigo may be of aural origin not connected with Meniere's disease. 

Hyperacusis (auditory hyperaesthesia) is an abnormal acuteness of hear- 
ing. It is observed in hysteria and hypnotic states. It may occur in facial 
paralysis. 

Dysacusis, or painful hearing, occurs in neurasthenic and hysterical 
conditions, in feeble people, in brain congestion, as in fevers, in meningitis, 
and in local inflammation of the ear. 

Impairment of hearing may be due to the presence of adenoids, enlarged 
tonsils, polypi, catarrhal conditions of the Eustachian tube, hypertrophic and 
atrophic rhinitis, etc. Boiler makers are apt to have deafness, and the 
hearing of the aged is not acute. Children with impaired hearing require 

special education, and the sense of hearing 
in deaf mutes may be developed by syste- 
matic hearing exercises. 

Treatment. — The causes just enu- 
merated should receive careful attention. 
Strict attention to the condition of the 
nasopharynx is indicated, viz., removal of 
adenoids and posterior hypertrophies of 
the inferior turbinals. Constitutional rem- 
edies, such as iron, arsenic, etc., are in- 
dicated in cases in which the general health 
is undermined. Iodide of potassium or 
sodium and mercury should be adminis- 
tered where syphilis is present. Inflation 
is indicated in cases of deafness due to chronic catarrh of the middle ear. 
In a certain number of cases where the perforation does not heal the use 
of an artificial drum membrane has been found serviceable, provided the 
discharge has ceased. In deafness due to internal ear disease strychnine 
and electricity may be tried. 

Aural Vertigo. — Meniere's disease is a name given to all cases of vertigo 
due to an affection of the ear. 

The cause and pathology are not known. 

Symptoms. — Sudden giddiness; the surrounding objects seem to revolve, 
or the patient may seem to be gyrating, usually from left to right. Walking 
or standing may be rendered impossible. The onset may be so abrupt as 
to cause the patient to fall. He may lose consciousness for a few minutes. 
Soon the dizziness passes away, but the patient is left prostrated. He is 
pale and bathed in cold perspiration. He may have nausea and vomit. 
Usually there is partial loss of hearing in one ear. 

Prognosis. — The paroxysms recur at irregular intervals. Sometimes 
they cease, but sometimes they become more frequent and deafness becomes 
complete. 




EAR FORMULARY 



811 



Treatment. — In robust patients, pilocarpine, subcutaneously, nx v to 
x of a 2 per cent solution every other day, may help. If there is high 
arterial tension, nitroglycerine may be used. Sodium bromide and sodium 
salicylate have been recommended. 



DIAGNOSTIC VALUE OF FLUID DISCHARGES FROM THE 
EAR IN HEAD INJURIES 

While in the majority of cases in which bleeding and welling of cerebro- 
spinal fluid from the ear are present a fracture of the middle fossa of the skull 
exists, these signs are not pathognomonic. 

The great bulk of the haemorrhage comes from the vessels of the arach- 
noid membrane and of the temporosphenoidal lobe of the brain, and not 
from the fractured bone. 

The path of the discharges is along the sheath of the auditory nerve, 
through the lamina cribrosa to the vestibule, thence through the middle 
ear and ruptured membrane to the external meatus. 

Excluding the extra risk of sepsis, the prognosis is, on the whole, better 
when these signs exist than when they do not. — Miles, Edinb. Med. J., 
November, 1905. 

FORMULARY 

1$ Cocain., gr. x to xx; 

01. anilin., 5j; 

Alcoholis, ._. 5j- 

M. : F. solut. Sig. : Anaesthetic for paracentesis. Saturate cotton 
and apply to the drum membrane. Children may have a few drops instilled 
into the ear. 

1$ Acid boric, gr. x; 

AqU8e ' \aa *tv 
Alcohol.,/ aa ' 5JV - 

M.: F. solut. Sig.: Ear drops for chronic purulent otitis, espe- 
cially when associated with granulations. 

To loosen wax previous to syringing, employ peroxide of hydrogen. 
For parasitic external ear canal disease employ absolute alcohol. 
Leeches for acute inflammatory conditions. Apply in front or behind 
the ear. 

For acute earache, use water at 100° F. by means of a glass ear tube with 
a recurrent flow. It is safe and effective and will allay pain and often 
prevent mastoiditis. In infants, breathe into the ear. For acute external 
earache, use a hot water bag. 



CHAPTER XXX 



OPHTHALMIC MEMORANDA 

Synopsis: General Remarks on the Sense of Sight, on Pupillary Phenomena, and on the 
Ophthalmoscope. — Injuries of the Eye and Foreign Bodies. — Diseases of the Eyelids. — 
Disease of the Lacrymal Apparatus. — Conjunctivitis and Trachoma. — Keratitis. — 
Disease of the Sclera, Ciliary Body, and Chorioid. — Iritis. — Glaucoma. — Disease of 
the Retina. — Disease of the Optic Nerve. — Cataract and Opacities. — Squint. — Eye- 
sight. — Formulary. 

GENERAL REMARKS 

Sense of Sight; Pupillary Phenomena; The Ophthalmoscope 

SENSE OF SIGHT 

Asthenopia is a condition characterized by fatigue and pain in or about 
the eyes, coming on shortly after near work (reading, writing, or sewing), 
and by inability to continue such work for any length of time. We dis- 
tinguish muscular, accommodative, and nervous asthenopia. 

Amblyopia is a partial loss of vision. 

Amaurosis is total blindness, either with or without any perceptible 
intraocular lesion, and may be caused by injuries, haemorrhages, poisons, 
such as alcohol, tobacco, quinine, salicylic acid, diabetes, uraemia, and 
hysteria. Night blindness and snow blindness are functional disorders. 

Retinal, or ocular, hyperaesthesia is an abnormal sensitiveness to light. 
Exposure to an extreme light or a long subjection to darkness or hysteria 
may be the cause. 

Photophobia (inability to endure light) is due to an irritation or in- 
flammation of the cornea. 

Hemianopsia, half blindness, is caused by lesions of the visual centres 
and optic tract (tumor, inflammations, softening, or haemorrhage). 

Scotomata are blind spots or areas in the visual field. 

Diplopia, or double vision, occurs in convergent concomitant strabismus, 
in insufficiency of the internal recti muscles, and in paralysis of the orbital 
muscles. 

Conjugate deviation, where both eyes turn decidedly to one or the other 
side, may be paralytic or spasmodic. The mechanism is not perfectly 
understood. Destructive lesions of the brain or of the pons may be re- 
sponsible. 

Mydriasis (iridoplegia) is due to paralysis of the sphincter of the iris. 
This causes dilatation and immobility of the pupil and is usually due to 
paralysis of the third nerve, 
812 



SENSE OF SIGHT 



813 



Cycloplegia, or paralysis of the ciliary muscle, usually due to the same 
cause as iridoplegia and commonly associated with it, causes loss of the 
power of accommodation. Local diseases of the eye, mydriatic drugs, 
diphtheria, and multiple sclerosis may be direct causes. 

Ptosis, or drooping lid, is due to paralysis of the levator palpebral superi- 
oris (third nerve), or the presence of some new growth in the lid, which 




Fig. 224. — Ophthalmoscopic Examination. 
The lamp should be placed to the right of the patient. 



may prevent the movement of the lid. There may be a functional ptosis in 
anaemic and nervous people, called "morning, or waking, ptosis." If the 
sympathetic fibres of the eye are paralyzed, we observe contraction of the 
pupil (meiosis). It does not respond to light, but does to accommodation 
(the Argyll Robertson pupil). If the sympathetic fibres are irritated, we 
observe dilatation of the pupil. 



814 



OPHTHALMIC MEMORANDA 



Strabismus, or squint, is a condition in which the visual axes do not meet, 
due to an incoordinate action of the external ocular muscles. Convergent 
strabismus is where both eyes are turned toward the nose. In divergent 
strabismus they are turned outward; in alternating strabismus the two eyes 
fix alternately. In concomitant strabismus the squinting eye has its full 
range of movement. In constant strabismics the condition is permanent. 

Paralytic strabismus is due most frequently to syphilis and rheumatism. 
It is also due to basal meningitis, intracranial tumors, injuries, compression 
from orbital tumors, or the diphtheritic poison. 

Spasmodic conjugate deviation of the eyes, from an irritation of the ocular 
nuclei or of the cranial areas or tracts of the brain, occurs in meningitis, 
hydrocephalus, semicircular canal lesions, and hysteria. Ocular diseases, 
refractive errors, muscle weakness, and paralyses may also cause it. 

Nystagmus, or rhythmical spasm, is an oscillation of the eyeballs, in a 
lateral, vertical, or rotatory direction. It occurs in some degenerative 
nervous disorders, such as disseminated sclerosis, in hereditary ataxia, in 
tumors, especially of the cerebellum, in other focal lesions, and in menin- 
gitis. We see it as the result of hereditary visual weaknesses and refractive 
errors of various kinds, in albinoes and in chronic hydrocephalus. It is 
usually found in neurotic conditions, associated with ocular defects, in 
epilepsy, chorea, hysteria, neurasthenia, and insanity. It may be a reflex 
symptom due to some remote irritation. It may occur in miners, whence 
it has been termed " miners' nystagmus." 

Spasm of the levator palpebral, of a tonic nature, is sometimes seen. 

Blepharospasm may occur without coexisting eye disease, but usually 
is caused by ocular trouble. It is a tonic spasm of the orbicularis palpe- 
brarum. Occasionally it is an hysterical symptom. 

Nictating, or winking, spasm is a clonic spasm of the orbicularis pal- 
pebrarum. It may be a symptom of hysteria or a part of the habit chorea. 

Lagophthalmus may indicate facial paralysis or brain tumor. 

Exophthalmus is found in Basedow's disease and other nervous derange- 
ments with exaggerated vascular tension. 

Neurasthenic individuals may have amblyopia and defective color per- 
ception and the phenomenon called muscat volitantes. 

The choked disc has the following appearance: (Edema of the papilla, 
the retinal arteries as a rule diminished in size, the veins distended and 
tortuous, the outlines of the disc lost. 

Ocular vertigo is a clinical phenomenon pointing to errors of refraction. 

Romberg's sign is a swaying of the patient when standing with the eyes 
closed and the feet (soles and heels) together — locomotor ataxia. 

THE PUPILS 

The pupils react to light and to efforts of accommodation. Light 
normally contracts the pupil; there is a direct response to light, and there is 
a direct response in accommodation, i. e., when the eyes are fixed on an 
object. The pupil dilates from irritation of the cervical sympathetic, as 
when the skin of the back of the neck is pinched. The pupil reflex may be 
normal, tardy, or absent. 



INJURIES OF THE EYE AND FOREIGN BODIES 



815 



An irregular outline of the pupil is due to iritis and subsequent adhesions. 
Inequality of the pupils is observed in healthy individuals, as well as in per- 
sons afflicted with a central lesion (syphilis). Mydriasis (dilated pupils) 
is due to irritation of the dilating mechanism or to paralysis of the con- 
tractors of the pupil, as observed in mania, acute delirium, amaurosis, 
cerebral ansemia, valvular heart disease (dyspnoea), neurasthenia, coma, 
diphtheritic paralysis, meningitis, the use of belladonna, etc. Unequal tran- 
sitory dilatation is not infrequent in tuberculosis. Unlimited dilatation 
may indicate irritation of the cervical sympathetic, from tumor or aneurysm 
or disease in the optic nerve. Mental derangements are often preceded by 
an alternating unilateral mydriasis. The pupil is also influenced by local 
disease of the eye. 

Unilateral contracted pupil (meiosis) may be caused by locomotor ataxia, 
general paralysis, or the pressure of an aneurysm on the sympathetic. It 
may be due to a basilar tumor or to adhesions from a former iritis. 

Bilateral meiosis is found, associated with inflammatory conditions, in 
photophobia, in all forms of spinal disease, in uraemia, in cerebral disease, 
and from the effects of opium, eserine, pilocarpine, or chloral. 

In the Argyll Robertson pupil we note response to accommodation, but 
not to light, an early characteristic of tabes. 

Immobility of the pupil is somewhat characteristic of brain syphilis. 

Hippus. — Rhythmical contraction and dilatation of the pupil, called 
hippus, may point to sclerosis of the brain, epilepsy, acute meningitis, or 
pressure of a brain clot. 

THE OPHTHALMOSCOPE 

As it requires constant application and experience to master the details 
of an ophthalmoscopic examination, the general practitioner will content 
himself with a knowledge of the appearance of a healthy background and 
the choked disc, and with an examination of the transparent media for 
opacities and foreign bodies. 

INJURIES OF THE EYE AND FOREIGN BODIES 

Injuries of the eye are common, and the loose subconjunctival tissue 
favors subconjunctival haemorrhage. It takes some time for the blood 
to be absorbed, and the application of hot water is perhaps the quickest 
method of assisting Nature to overcome the discoloration. Should a seg- 
ment of the iris be detached we instill atropine. 

Laceration at the pupillary margin is usually associated with haemorrhage 
into the anterior chamber. This clot may remain for weeks. In such cases 
it is best to keep the pupil dilated with atropine. 

Partial or total luxation of the lens and traumatic cataract may be caused 
by injury. Very little can be done in subluxation of the lens. Total lux- 
ation may necessitate extraction. Traumatic cataract may develop at once 
or very gradually. The prognosis must therefore be guarded. 

Perforating injury at the sclerocorneal margin is a most serious lesion 
and very often necessitates removal of the eyeball. 

Haemorrhage into the vitreous may clear up in a few days under rest 



816 



OPHTHALMIC MEMORANDA 



in bed and atropine, or there may be floating opacities in the vitreous with 
somewhat impaired vision. 

Traumatic detachment of the retina must be treated by rest. Superficial 
wounds of the conjunctiva and cornea, if not infected, heal rapidly. 

Infected wounds show a discharge and purulent infiltration. In such 
cases the use of the actual cautery may be indicated, followed by atropine. 
Wounds involving the ciliary body are serious and may end in panophthal- 
mitis from infection, for which enucleation is the treatment. 

Wounds complicated by the presence of foreign bodies on the eyeball 
are serious. If the foreign body is of metal which can be magnetized, 
removal by the electromagnet should be attempted. 

Burns of the conjunctiva and cornea are not infrequent and may result 
in a slow healing ulcer and purulent discharge, with the danger of total 
destruction of the cornea. 

In lime burn of the eye the lime particles should be removed and a 
solution of sugar applied, the patient put to bed, and the eye kept clean 
with boric acid solution. The pupil must be kept dilated with atropine. 
It is also important in such cases to instill a drop of any pure oil into the 
eye every two hours. Small foreign bodies on the cornea can be seen by 
means of a focal illumination and must be removed. 

Foreign bodies in the conjunctiva can be seen by everting the lids, and 
must be removed. During such manipulations the eye can be made anaes- 
thetic by means of a few drops of a 2 per cent cocaine solution. 

Tumors, cysts, and parasites in and about the eye are of the same nature 
as in other localities, and require surgical treatment. 

DISEASES OF THE EYELIDS 

Blepharitis (blepharitis marginalis, ciliaris) is characterized by redness 
of the lids with the formation of crusts. It is either primary, due to infection 
by a microorganism, or secondary, due to conjunctivitis, errors of refraction, 
or eczema of the face. 

Treatment. — Cleanliness, careful bathing with hot water and boric 
acid, and the application of yellow oxide of mercury ointment, 1 per cent, 
also constitutional treatment. 

Hordeolum (Sty) and Chalazion. — Hordeolum is a small furuncle situated 
at the margin of the lid. A chalazion generally appears somewhat remote 
from the margin of the lid. It is a meibomian retention cyst, generally 
without heat, redness, or pain. 

Treatment. — Hot applications and a thorough evacuation of the con- 
tents is the treatment for sty. If an incised and evacuated chalazion fills 
up again, its radical removal is indicated. 

Warts, nasvi, epithelioma, papilloma, syphilitic gumma, and eczema are 
occasionally observed on the lids, presenting the same symptoms as on other 
parts of the body. The same may be said of the treatment. 

Blepharospasm, or involuntary closure of the lids, is either clonic in 
nature and due to errors of refraction or nervous disturbances, or tonic in 
nature, as a result of ulcerative conditions of the cornea, conjunctiva, etc. 

The treatment is, therefore, based upon the removal of the cause. 



CONJUNCTIVITIS AND TRACHOMA 



817 



Ptosis, or drooping of the upper lid, is either congenital or acquired; 
in the latter event it is due to traumatism, syphilis, or other diseases affecting 
the function of the third nerve. 

Treatment. — Congenital ptosis is usually remedied by removal of an 
elliptical piece of skin with the underlying muscle from the upper lid and 
stitching together the edges of the wound. The other varieties of ptosis are 
treated in accordance with their respective causes. 

Entropion (Trichiasis, Distichiasis) . — A displacement of the cilia toward 
or against the cornea usually develops secondarily to granular lids. It is 
a painful affection and may give rise to ulcerations of the cornea. It is 
sometimes spastic in nature. 

Treatment. — Frequent removal of the cilia is sometimes effective in 
relieving this condition, otherwise an operative procedure is required with 
the object of correcting the direction of the cilia. 

Ectropion is an eversion of the margin of the lid with exposure of the 
conjunctiva. It is generally due to traumatism, especially burns, but some- 
times to hypertrophy of the conjunctiva associated with trachoma. 

Treatment. — Mild cases sometimes yield to local astringents; in severe 
cases operative interference is indicated. 

Puffy eyelids are observed in Bright 's disease and cardiac disease; 
trichiniasis, in local eczema and neuropathic cedema and in all inflammatory 
conditions in or about the eye. 

DISEASE OF THE LACRYMAL APPARATUS 

This usually manifests itself as an obstruction to the flow of tears through 
the lacrymal passages into the nose. This obstruction may be situated 
on the orbital or nasal part of the tear duct, and as a result the eye is con- 
stantly full of tears which run over the margin of the lid (epiphora). In- 
flammation of the lacrymal sac, dacryocistitis, may end in lacrymal fistula. 

Treatment. — The aim of treatment is to remove the cause if possible 
and to endeavor to reestablish free drainage by means of bougies and needles. 
Treatment of the inferior turbinated body of the nose is frequently essential in 
this class of cases. 

CONJUNCTIVITIS AND TRACHOMA 
Conjunctivitis, or inflammation of the conjunctiva, is characterized by 
redness, swelling, supersecretion, and more or less pain and photophobia. 

Simple conjunctivitis is caused by slight irritations and usually runs 
a brief and benign course. It differs from epidemic catarrhal conjunctivitis 
(pink eye) in not being contagious; furthermore, the secretion in simple 
conjunctivitis is mucous, while in the epidemic variety it is mucopurulent. 
Acute catarrhal conjunctivitis sometimes becomes chronic and leads to a 
follicular hypertrophy of the conjunctiva, the so called "granular lids." 
The latter condition should not be confounded with the highly contagious 
form of conjunctivitis which is known as trachoma. In this affection the 
conjunctiva is studded with small, at first discrete, elevations which coalesce 
and form large, hard masses as the disease progresses. Owing to friction 
exerted by these granulations, the cornea frequently becomes ulcerated — 



818 



OPHTHALMIC MEMORANDA 



"pannus" — and if the irritation continues unabated, the cornea may be 
partially destroyed, giving rise to defective vision. 

Much more rare than this variety of conjunctivitis is that caused by 
gonorrhceal infection and known as purulent, or gonorrhoeal, conjunctivitis 
(purulent ophthalmia). It resembles ophthalmia neonatorum (q. v.) in 
its symptomatology and course. 

The practitioner is occasionally confronted with cases of diphtheritic con- 
junctivitis. It is a very destructive disease. The infection is usually pri- 
mary, although rarely it is secondary to diphtheria of the nasopharynx. 
Diphtheritic conjunctivitis is characterized by the formation of a false 
membrane and by the presence of diphtheritic bacilli in the discharge from 
the eyes, but not every pseudomembranous conjunctivitis is diphtheritic. 

As a result of local or general conditions, the conjunctiva may be dry or 
moist. It is yellow in jaundice, pearly white in anaemic conditions, and fre- 
quently injected or inflamed from local and general causes. Subconjunctival 
haemorrhage may result from a severe strain, as in coughing, etc., or injury. 

General Treatment. — In all forms of conjunctivitis frequent cleansing 
of the eyes with boric acid solutions is of primary importance. Mild cases 
usually yield to this alone. Severer cases require daily applications of 
silver nitrate (1 per cent). Pronounced inflammatory symptoms should be 
treated with ice cloths. When cold applications are not well borne, warm 
applications are indicated. The surgical treatment of trachoma consists 
in gentle expression of the granules by means of the trachoma forceps 
designed for this purpose. This operation should be done under anaesthesia. 
The treatment of gonorrhoeal conjunctivitis is described under Ophthalmia 
Neonatorum (q. v.). In diphtheritic conjunctivitis, diphtheria antitoxine 
should be employed in addition to cleanliness and applications of ice cloths 
and nitrate of silver (from 1 to 2 per cent). In the management of con- 
tagious ophthalmia in infants or adults the first concern ought to be the pre- 
vention of the propagation of the disease to sound eyes. 

KERATITIS 

The characteristics of keratitis are congestion, circumcorneal injection, 
pain, photophobia, excessive lacrymation, haziness, and impaired vision. 
It usually develops secondarily to diseases of the lids or to traumatism 
(from secondary infection). An exception to this rule is made by inter- 
stitial, or parenchymatous, keratitis, which is generally syphilitic in nature. 
In the beginning the inflammation of the cornea is superficial, but if it is 
not remedied early the cornea may undergo ulceration or suppuration. The 
latter conditions may lead to perforation of the cornea with involvement 
of the iris, resulting in permanent impairment of vision. 

Phlyctaenular keratitis usually begins with small vesicles on the palpebral 
conjunctiva (phlyctaenular conjunctivitis). The vesicles gradually invade 
the ocular conjunctiva, break down, and form small ulcers. This form of 
keratitis is analogous to eczema of the skin and is generally observed in 
scrofulous children. 

General Treatment. — The eyes should be cleansed with boric acid solu- 
tion, bathed in hot water, and protected from bright light. Atropine (£ to 



IRITIS AND GLAUCOMA 



819 



1 per cent) instillations should be employed to prevent iritic adhesions, also 
yellow ointment in the eye in case of central phlyctaenula of cornea. In 
syphilitic keratitis this treatment should be supplemented by antisyphilitic 
treatment. As a general rule constitutional treatment is necessary. Corneal 
inflammation frequently terminates by leaving opacities of the cornea. 

DISEASES OF THE SCLERA, CILIARY BODY, AND CHORIOID 

Gout, rheumatism, syphilis, and traumatism are the chief causes of the 
diseases in question. 

Episcleritis (scleritis) occurs in circumscribed, slightly nodular sub- 
conjunctival patches of a bluish pink color. It is not infrequently associ- 
ated with chronic keratitis, iritis, or chorioiditis. 

Cyclitis is an inflammation of the ciliary body, and may occur as a serous 
or as a suppurative inflammation. It is manifested by deep circumcorneal 
injection, with pain, and by tenderness on pressure. In serous cyclitis oblique 
examination discloses haziness of the anterior portion of the vitreous as 
well as the aqueous; in the plastic form a grayish mass behind the lens 
often obscures vision. Suppurative cyclitis is usually associated with 
suppurative chorioiditis and iritis. 

Chorioiditis is characterized by a diffuse haziness of the vitreous, which 
contains minute floating opacities, hyperasmia, and serous or plastic exuda- 
tion of the chorioid. After absorption of the exudation, atrophic patches 
are left behind which greatly impair vision. This is especially the case in 
the syphilitic and tuberculous varieties and in old myopic conditions. 

Treatment. — Iodides and tonics internally. Hot applications locally. 

IRITIS 

Iritis. — Inflammation of the iris is characterized by contracted pupil, 
impaired mobility of the iris, and, in the presence of adhesions, irregular 
dilatation of the pupil if light is reflected into the eye or a mydriatic is in- 
stilled. There is also marked injection of the circumcorneal blood vessels, 
and a rosy zone encircles the cornea. Pain is severe in acute cases, and 
especially at night. Iritis may be caused by traumatism, syphilis, rheuma- 
tism, or tuberculosis. 

Syphilitic iritis may appear in the serous, spongy, or gummatous form. 
The formation of gummata in the substance of the iris is pathognomonic 
of syphilis. It is accompanied by very severe pain. Rheumatic iritis is 
very prone to relapses and runs a very slow course. The pain is moderate. 

Treatment. — Hot fomentations and atropine. Leeches if the conges- 
tion and pain are very pronounced. Constitutional remedies in the presence 
of syphilis, rheumatism, etc. Permanent adhesions (posterior synechia?) 
may be treated by removal of a portion of the iris. 

GLAUCOMA 

Glaucoma sometimes comes on insidiously, with rapid increase in pres- 
byopia, making frequent changes of glasses necessary for reading; iridescent 
vision, consisting of a halo around lights, the outer ring being red and the 



820 



OPHTHALMIC MEMORANDA 



inner one bluish green; diminution in the field of vision, and increased 
tension of the eyeball. Gradually these symptoms become intensified, the 
cornea becomes steamy, like glass that has been breathed upon, the pupil 
dilated, and the increased tension of the globe becomes more pronounced, 
finally causing it to reach a stony hardness, and the pupil becomes partly or 
fully dilated. 

The acute form is characterized by intolerable pain in the eyeball and 
by pronounced increase of tension. There is conjunctivitis, the cornea is 
anaesthetic and steamy, the aqueous is turbid, the iris is discolored, and the 
pupil is dilated. An attack may end in blindness. There are frequent 
recurrences and in cases of glaucoma not subjected to operation blindness is 
the final result. 

Treatment. — Early recognition and treatment are of great importance. 
Mild cases sometimes yield to warm local applications and to the instillation 
of solutions of eserine, gr. j to 5j (1: 500) or of pilocarpine in the strength 
of \ per cent. Severe cases require an immediate operation (iridectomy). 

DISEASES OF THE RETINA 

Affections of the retina usually form a symptom of constitutional diseases, 
and according to their cause they are divided into albuminuric, haemor- 
rhagic, and syphilitic retinitis. In albuminuric retinitis whitish patches 
appear in the retina in the vicinity of the fovea centralis. In hosmorrhagic 
retinitis, which usually occurs in old people and almost always accom- 
panies chronic interstitial nephritis, the arterial walls become much thick- 
ened and, as the disease progresses, permit of the escape of blood. Syphi- 
litic retinitis is characterized by excessive exudations and more or less profuse 
haemorrhages in the retina. In all forms of retinitis there is marked dis- 
turbance of vision and in severe cases even complete blindness. 

Treatment. — Removal of the cause. 

DETACHMENT OF THE RETINA 

Detachment of the retina is due to an effusion of a serous liquid from 
the chorioid between it and the retina, and may be caused by a diseased 
vitreous, or chorioid, high myopia, a blow on the eye, etc. The subjective 
symptoms depend upon the degree and the amount of the detachment. The 
prognosis is highly unfavorable. 

DISEASES OF THE OPTIC NERVE 

Optic neuritis is generally caused by diseases of the brain or the meninges, 
syphilis, or lead poisoning. It manifests itself by haziness and swelling 
of the optic disc, gradual enlargement of the veins, and diminution in the 
size of the arteries. Haemorrhages may appear both upon and around the 
disc. The extreme condition of optic neuritis is called "choked disc." 

Optic atrophy is characterized by paleness of the disc, which becomes 
more white as the disease progresses. There is gradual loss of vision, 
which progresses by concentric limitation of the field. Optic atrophy is 



EYESIGHT AND EYE STRAIN 



821 



caused by the same a?tiological factors which are operative in the production 
of optic neuritis and also by diseased processes of the retina, by embolism 
of the arteria centralis retinae, or by tabes dorsalis. 

Treatment. — Removal of the cause whenever possible. Attention to 
the general condition of the patient. Strychnine internally; this remedy is 
especially valuable in diseases of the optic nerve due to poisoning by alcohol, 
tobacco, etc. 

CATARACT AND OPACITIES 

Cataract is an opacity of the crystalline lens. Opacities occurring in the 
lens usually have a whitish appearance when examined by direct or oblique 
illumination. Certain forms of nuclear cataract give an amber tint, and in 
the exceptional cases of black cataract the color is deep brown. In lamellar 
cataract examination discloses a circular line of opacity which is most 
dense at its periphery. At first the patient usually experiences disturbance 
of vision in the form of dark lines or branching opacities, which are pro- 
jected into space. The causes of cataract are old age, traumatism, exposure, 
privation, etc., i. e., interference with the nutrition of the lens. It not 
infrequently accompanies diabetes mellitus. 

The treatment is surgical. 

SQUINT, STRABISMUS 

Strabismus (squint) is concomitant and paralytic. In order to ascertain 
the existence of strabismus, the patient is caused to fix the eyes on an object, 
and then they are alternately covered and uncovered. In order to dis- 
tinguish concomitant from paralytic strabismus, the eyes are made to 
follow the movements of an object in various directions; in concomitant 
strabismus both eyes will move to the same extent and their movements 
will not be restricted in any direction; in paralytic strabismus the move- 
ment of the affected eye will be restricted in the direction of the action of 
the paralyzed muscle. 

Treatment. — In concomitant strabismus errors of refraction should be 
corrected, and if the affection persists after the tenth year of age, tenotomy 
should be performed. In paralytic strabismus attention should be directed 
to the cause, such as syphilis and diphtheria. About 25 per cent of cases of 
strabismus may be overcome by non-operative treatment. 

EYESIGHT AND EYE STRAIN 

Emmetropia is the normal condition of the refracting media of the eye, 
in which the anteroposterior diameter is of the right length so that the rays 
of light from distant objects come to a focus upon the retina. 

Eye Strain. — The symptoms of eye strain are multiple, and their origin 
in the eyes is often overlooked. The eyeballs ache. There is supraorbital 
pain or a pressure back of the eyes; letters on the page run together if one 
persists in using the eyes, and black spots dance about in the field of vision. 

Hypermetropia (far-sightedness) is a condition in which the anteropos- 
terior diameter is too short; the parallel rays come to a focus behind the 
retina. 



822 



OPHTHALMIC MEMORANDA 



Myopia (near-sightedness) is that form of error of refraction in which 
the anteroposterior diameter is elongated; parallel rays are thus brought 
to a focus in front of the retina. This condition may be congenital or 
acquired. 

Astigmatism is a condition of the refraction of the eye in which rays of 
light passing through one of the principal meridians are refracted differently 
from those passing through the other meridians. It is produced by a 
difference in the curve of different parts of the cornea or, sometimes, of the 
crystalline lens. 

Presbyopia is the natural change in the eyesight, viz.: the diminution 

of the power of accommodation, accompanying advancing years. 

Treatment. — Correction of refraction. Hypermetropia is corrected by 
means of a convex (x) lens; myopia by the use of a concave (-) or dispers- 
ing lens; astigmatism by the use of cylindrical glasses so adjusted as to 
correct the difference between the refraction of the principal meridians in 
addition to correction of other errors of refraction if present. 



EYE FORMULARY 



Boric acid solution, 4 per cent; 

Sulphate of zinc solution, gr. 1 to oj; 

Nitrate of silver solution, 1 per cent; 

. , , , , ,. ( 4 per cent for children ; 

Atropine sulphate solution, -. ; , , , 

L 1 ' (1 per cent tor adults; 

Pilocarpine solution, ^ per cent; 

Eserine solution, gr. 1 to oj; 

Cocaine solution, 2 per cent; 

Bichloride of mercury solution, as an 

antiseptic in eye cases, 1 to 5,000; 

Yellow oxide of mercury ointment, \ to 1 per cent. 



CHAPTER XXXI 



ANAESTHESIA, INTOXICATIONS, MISCELLANEOUS AILMENTS, 
KEEPING CASE RECORDS AND ACCOUNTS 

Synopsis: Remarks on General and Local Anaesthesia. — List of Poisons and Antidotes. — 
Gas Poisoning. — Ptomaine Poisoning. — Grain Poisoning. — Poisoning by Pigments and 
Preservatives. — Snake Bites. — Insect Bites. — Drug Habits and Alcoholism. — Seasick- 
ness and Mountain Sickness. — Hydrophobia. — Traumatic Tetanus. — Case Records and 
Accounts. 

ANESTHESIA 

REMARKS ON LOCAL AND GENERAL ANAESTHESIA 

General Ancesthesia 

This is employed to relieve pain in surgical and obstetrical manipula- 
tions. It is employed in severe eclampsia, in setting fractured and dis- 
located bones, in making important x ray exposures, in the case of 
children who would not be apt to hold still, and for facilitating painful 
examinations for diagnostic purposes. 

The risk of artificial sleep must be assumed by the person who is to be 
benefited, with the understanding that the ansesthetizer shall be qualified 
by actual practical experience and shall use all rational precautions and 
safeguards. When anesthesia is induced for diagnostic purposes, the 
patient has a right to expect that the information thus elicited shall be final. 

Chloroform is about ten times as dangerous as ether, but is to be pre- 
ferred in the presence of renal insufficiency and in obstetrical practice. 
It is contraindicated in myocardial weakness and in very prolonged opera- 
tions, but is again indicated in cases in which complete relaxation cannot 
be obtained from ether. It is administered by dropping it upon a mask 
or napkin from a drop bottle. Chloroform is not inflammable. When 
chloroform kills, the patient dies quickly. Chloroform anaesthesia can be 
made more safe by combining oxygen and chloroform by means of a special 
inhaler. 

Ether is the safer anaesthetic in unskilled hands, but it may cause 
death some time after its administration, yet it is to be preferred as a 
rule in the presence of cardiac insufficiency. Its administration is ac- 
complished by means of a cone made out of paper and a towel. Ether 
is highly inflammable. 

Nitrous oxide and ethyl bromide are used for anaesthesia of short dura- 
tioB T after is administered by means of a napkin or chloroform mask. 

823 



824 ANESTHESIA, INTOXICATIONS, MISCELLANEOUS AILMENTS 



Nitrous oxide is inhaled from a mask connected with an inflatable balloon 
and a gas tank. This anaesthetic is very safe, and is used in dentistry and 
for minor operations, and it may be given as a preliminary to ether or 
chloroform. No special apparatus is necessary for combined anaesthesia, 
but in skilled hands the Bennett inhaler gives excellent results. 

Other requisites for ancesthesia are a mouth gag, a tongue forceps, a needle 
and silk for tongue traction, swabs securely fastened to long handles, a sterile 
hypodermic syringe) and needles. 

Drugs to be used to combat circulatory failure : Strychnine, gr. 
to tV> camphor in oil (1 to 15), gtt. x to xx, atropine sulphate, gr. yQj 
whiskey, digitalis. 

The necessary paraphernalia for enteroclysis, hypodermoclysis, and 
venous infusion should also be on hand. 

Preliminaries to Anaesthesia. — Castor oil or a saline laxative should be 
given the evening before an operation if there is time, and an enema in the 
morning, before the operation. No food should be taken for six hours 
before the operation. Empty the bladder before the operation. Remove 
superfluous garments and false teeth. Place the patient in the recumbent 
position with the head low. Anoint the mouth, nose, and cheeks with 
vaseline. Instruct the patient to breathe deeply and regularly, and allow 
no talking until the patient is under the influence of the anaesthetic. 
Finally, the patient's extremities are to be placed in such a position as 
not to favor pressure paralysis. 

To administer an anaesthetic skilfully requires practice, as no two indi- 
viduals behave alike. Anaesthesia may be deep and profound or slight and 
superficial. Frequently the corneal reflex is abolished, but the muscles are 
rigid and the patient reacts to pain. Then it may become necessary to 
substitute chloroform for ether, or vice versa, or use a combination of 
both. The respiration is to be carefully watched, also the pulse. Stimu- 
lants may have to be employed during a lengthy anaesthesia, and in some 
cases it is well to inject morphine before administering the anaesthetic. 

All these points are to be learned at the bedside and not from textbooks. 
Anaesthesia should imitate sleep and this should be accomplished with the 
least amount of the anaesthetic. A girl or woman should not be anaesthetized 
except in the presence of a third party, on account of the danger of erotic 
excitement. Mucous collections in the throat during anaesthesia are man- 
aged by turning the patient's head to one side and allowing mucus and 
saliva to gravitate out of the mouth. It may be necessary to use a mouth 
gag and swab for this purpose and to stop the anaesthetic until the danger 
from interrupted breathing is past. 

Premonitory symptoms of vomiting may frequently be stopped by 
pushing the anaesthetic. Attacks of vomiting are managed very much like 
mucous collections in the throat. Interrupted breathing during anaesthesia 
is to be looked upon as a danger signal. In such instances the anaesthetic 
is to be laid aside, and the head lowered, the jaw pushed forward, and 
rhythmical traction of the tongue practised. Ammonia may be held to 
the nose and atropine sulphate or strychnine may be administered sub- 
cutaneously. 



GENERAL TREATMENT FOR INTOXICATIONS 



825 



Local Anaesthesia 

Local anaesthesia is accomplished by means of an ether or chloride of 
ethyl spray or by subcutaneous injection of a 2 per cent sterile solution of 
cocaine or eucaine in water. 

Spinal anaesthesia is performed by injecting \ to \ grain of sterile cocaine 
in solution into the subdural space in the manner described under Spinal 
Puncture. Spinal anaesthesia is to be used only in exceptional cases. 

In Schleich's infiltration method, very weak solutions of cocaine and 
morphine are injected so as to thoroughly infiltrate the tissues to be cut. 

Local anaesthesia for minor rectal operations by means of sterile water 
injections, which distend the tissues, is recommended by Dr. S. Gant, of 
New York. 

A new local anaesthetic has been introduced by M. Fourneau, of Paris, 
under the name of stovaine, a synthetic product of the laboratory which 
gives the same results as an equal solution of cocaine and is decidedly less 
toxic. It is dissolved in distilled water, making a 1 per cent solution, of 
which from 15 to 30 drops are injected subcutaneously in neuralgia and for 
local anaesthesia. 

INTOXICATIONS 

POISONS AND ANTIDOTES 

When poison has been swallowed, we should: 

1. Endeavor to get rid of the poison. 

2. Administer the antidote at once or as soon as possible. 

3. Treat symptoms, such as collapse, burned surfaces, etc. 

To provoke vomiting, use large quantities of warm water, at least a pint 
at a time. To this we may add 3j of mustard, or 5j of powdered ipecac, 
or 5 i of the syrup of ipecac; insert the finger into the throat and adminster 
apomorphine, gr. T V to J, subcutaneously. For cases of unconsciousness 
where emetics fail, use the stomach tube. 

Bland liquids are milk, raw eggs, oil, mucilage, gruel, barley water, 
condensed milk, etc. 

The alkaline antidotes usually at hand are ammonia and water, soap, 
lime, whiting, soda, magnesia (Epsom salts), chalk, tooth powder, plaster, 
whitewash, wood ashes, lime water, etc. 

The acid antidotes usually at hand are vinegar and lemon juice. 

The stimulants usually at hand are whiskey, ammonia, tea, coffee, etc. 

// the nature of the poison is unknown, provoke repeated vomiting, 
washing the stomach clean, without the tube if possible; give bland liquids, 
stimulate, and keep up breathing if necessary. 

General Treatment 

Acids, Sulphuric, Nitric, Hydrochloric, Oxalic. — Give an alkali (see 
above). Provoke vomiting; try to avoid the stomach tube; give bland 
fluids (ice cream) ; secure rest ; relieve pain ; stimulate if necessary ; feed by 
nutrient enemata. 



826 ANAESTHESIA, INTOXICATIONS, MISCELLANEOUS AILMENTS 



Hydrocyanic Acid and Potassium Cyanide. — Fresh air, an emetic, or 
the stomach tube; potassium permanganate; stimulate; give diluted am- 
monia water or chlorine water; cold effusions; atropine, gr. jfo, sub- 
cutaneously. 

Carbolic Acid and Creosote. — Give Epsom salts, strong alcohol, dilute 
sulphuric acid, glycerine and oil; atropine subcutaneously, gr. T fg-; emetics, 
apomorphine, gr. ^ to \, the stomach tube if necessary; white of egg; 
amyl nitrite; stimulants; artificial heat; castor oil. 

Alkalies, Ammonia, Soda, Potash, Lye, Chlorate of Potassium. — Give 
vinegar, lemon juice, orange juice, or other acids; fixed oils; bland liquids; 
secure rest; relieve pain; stimulate if necessary. Chlorate of potassium 
acts upon the heart and kidneys. 

Arsenic, Paris Green, Scheele's Green, Fowler's Solution, Rat Poison. — 
Emetic or stomach tube; give hydrated oxide of iron (made by adding 
to a solution of the perchloride of iron, or the sulphate of iron, an excess of 
sodium carbonate (washing soda) or carbonate of potassium or magnesia, 
and filtering through a cloth); castor oil; secure rest; stimulate. Chronic 
arsenicism develops renal changes and paralysis. 

Mercury, Corrosive Sublimate, Antimony, Tartar Emetic. — Emetics; 
lavage; give some infusion containing tannic acid; raw eggs and milk; 
bland liquids; castor oil; stimulate. 

Copper Salts, Chronic Copper Poisoning among Artisans. — Albumen 
(milk, raw eggs); stomach tube; emetics; bland liquids. Symptoms of 
chronic copper poisoning: dyspepsia, ansemia, nervousness. In some of 
the manufacturing districts in Germany men work only three months a 
year in the glazing department by law. 

Lead Salts. — Emetics or stomach tube; give Epsom salts or dilute 
sulphuric acid; milk, raw eggs, and water; relieve gastrointestinal pain; 
potassium iodide to help eliminate the drug. In chronic lead poisoning, 
there are blue gums, lead colic, constipation, and extensor paralysis. 

Phosphorus, Matches, Rat Poison. — Provoke vomiting by repeated 5 gr. 
doses of sulphate of copper, the antidote; potassium permanganate solution, 
\ to \ per cent; give a saline purgative, but no oils nor fats. In chronic 
phosphorus poisoning, stomatitis and periostitis result. 

Nitrate of Silver (Lunar Caustic). — Give strong salt and water; provoke 
vomiting; repeat many times, as it is antidote and emetic. 

Iodine. — Emetics or stomach tube; starch and water; bland fluids; 
stimulate and relieve pain. 

Opium, Morphine, Laudanum, Paregoric, Etc.- — Emetic; stomach tube; 
potassium permanganate by the mouth or subcutaneously; ammonia; hot 
strong coffee per rectum; atropine subcutaneously; oxygen; keep awake; 
artificial respiration; lingual traction; amyl nitrite inhalation; interrupted 
current; use catheter and give rectal irrigation with warm saline solution. 

Chloral Hydrate, Paraldehyde. — Emetic or stomach tube; artificial heat; 
massage; stimulate; strychnine; amyl nitrite; artificial respiration. 

Nux Vomica, Strychnine, Picrotoxin. — Emetic or stomach tube, apo- 
morphine, gr. \; animal charcoal or tannic acid; bromides and chloral; 
amyl nitrite; chloroform anaesthesia for convulsions; curare; artificial 
respiration. 



ANTIDOTES FOR POISONS 



827 



Aconite, Veratrum Viride. — Emetic or stomach tube; stimulate; apply 
heat; atropine; artificial respiration. 

Hemlock, Toadstool. — Provoke vomiting and give a purge; tannic or 
gallic acid; stimulate well; keep up the breathing. 

Belladonna (Deadly Nightshade), Atropine, Hyoscyamus or Hyoscya- 
mine, Duboisia or Duboisine, Stramonium or Daturine (Jimson, or James- 
town, Weed), Tobacco. — Emetic or stomach tube; stimulate; enema of hot 
coffee; artificial heat; morphine; pilocarpine; physostigmine; artificial 
respiration. 

Alcohol, Wood Alcohol. — Stomach tube or emetic; ammonia and water; 
faradism; cold douche; cold applied to the heart. 

Poisonous Gases, Carbonic Acid Gas, Sulphureted Hydrogen, Illuminat- 
ing Gas. — Fresh air; oxygen; artificial respiration; amyl nitrite or nitro- 
glycerine; stimulation. 

Chronic Sewer Gas Poisoning. — Although workers in sewers are remark- 
ably free from disease, it is generally believed that a prolonged exposure 
to noxious gas and the powerful odors from foul water may cause in acute 
types nausea, vomiting, colic, and fever, followed perhaps by collapse or 
coma. In more chronic forms there may apparently result a low form of 
fever with or without chills. 

Treatment. — Remedy the drainage pipes or remove to sanitary sur- 
roundings. 

Poison Ivy. — (Edematous erythema may spread over the entire body. 
Give a brisk cathartic. Apply lime water, lead water, or some simple 
ointment. 

Ptomaine Poisoning, Poisoning from Meat, Pork, Sausage, Head Cheese, 
Beef, Veal, Mutton, or Fish. — From tainted or diseased meat, we observe 
vomiting, pain, and diarrhoea; it may simulate cholera; there may be wake- 
fulness, delirium, headache, and changes in the pupils; the skin may show 
roseola, wheals, or urticaria; high fever or normal temperature; pulse 
accelerated or slow; thoracic oppression; patients may be prostrated; 
tendency to relapse; death may occur. 

Treatment. — Symptomatic; make the patient drink warm water and 
induce vomiting; enemata, stimulants, baths. 

Poisoning from Mussels. — Profound nervous symptoms, slight gastro- 
intestinal disturbances; numbness, coldness, no fever, dilated pupils, rapid 
pulse; death may come in a few hours. 

Treatment as for ptomaine poisoning. 

Oysters and Lobsters Which Are Not Fresh. — Gastrointestinal poison- 
ing, faintness, prostration, perhaps fever. 
Treatment, that of ptomaine poisoning. 

Poisoning from Milk, Ice Cream, Cheese, Etc. — Poisoning from milk is 
spoken of in the section on Paediatrics (Cholera Infantum). 

The various milk products, cheese, custard, ice cream, etc., may be very 
poisonous from ptomaines, and cause severe gastrointestinal symptoms. 

The treatment is the same as given above. 



828 ANAESTHESIA, INTOXICATIONS, MISCELLANEOUS AILMENTS 



Grain Poisoning 

Ergotism. — Meal may be contaminated with the ergot fungus, and its 
prolonged use will cause poisoning. There are two forms of intoxication. 
One begins with anaesthesia, tingling, and pains, in the toes and fingers 
usually, with spasmodic movements of the muscles, and a gradual stasis 
of the blood, terminating in gangrene. The other form shows nervous 
symptoms; the patient often complains from ten to fourteen days of head- 
ache and tingling sensations, possibly with slight fever and cramps in the 
muscles with contractures develop. The arms are flexed and the legs and 
toes are extended. These cramps come in spasms and may last from a 
few hours to many days. Relapses are frequent. Eclampsia develops in 
the most severe cases. Death may occur in a convulsion. Delirium may 
occur at first, and in chronic poisoning melancholia or dementia may result. 
Posterior spinal sclerosis may result from chronic poisoning with ergot. 

Lathyrism (lupinosia) is a poisoning produced by using meal made from 
a grain popularly known as chick pea. It causes a spastic paraplegia in- 
volving the legs, which may proceed to complete paraplegia. India, Italy, 
and Algiers are the countries in which it has been noticed. 

Pellagra (maidismus) , a diseased condition found extensively in parts 
of Italy, France, and Spain, is supposed to be caused by using maize which 
has fermented or is diseased. At first there are indefinite symptoms, 
debility, pains in the back, sleeplessness, digestive disturbances, and some- 
times diarrhoea. The pellagral erythema appears in the spring, and is 
followed by desiccation and exfoliation of the epidermis, which becomes 
very dry. Sometimes there is a suppurative process underneath the crusts. 
With these skin conditions there are digestive disturbances, salivation, 
dyspepsia, and diarrhoea, which may be hgemorrhagic. In the milder cases, 
after a few months recovery gradually takes place. 

In the severe and chronic forms we observe backache, headache, spasms, 
paralysis, and mental disturbances. The paralysis affects the legs and 
may lead to paraplegia. Melancholia or suicidal mania may occur after 
several attacks, and there may result a profound cachexia. 

Treatment. — The maize should be properly inspected and preserved. 
The patient should be removed from the infected district, and have a change 
of diet. Elimination and stimulation are indicated. 

Various Poisons — Insect and Snake Bites 

Pigments used in jellies and candies have produced poisoning. 

Pigments in stockings and underwear may produce local eczema and 
constitutional symptoms. Early recognition is important. The treatment 
is symptomatic. 

Preservatives, such as salicylic acid, boric acid, and formalin, have been 
used in foods in such large amounts as to cause intoxication. 

Lead and tin, used in canning fruits, vegetables, etc., have also caused 
poisoning. 

Flies have been known to carry infection to food which has communi- 
cated the disease to the person eating it. Tuberculosis, cholera, and typhoid, 



VARIOUS POISONS 



829 



fever have been contracted by eating food infected with the germs of these 
diseases. 

The treatment is self-evident when the nature of the poison is known. 

Snake Bites. — In this country there are few snakes, except the rattle- 
snake, the bites of which are poisonous. The poison of this snake, as well 
as that of others, does not affect one if swallowed, provided there are no 
abrasions in the mouth, but if it enters the circulation it is very poisonous. 
We observe dyspncea, cramps, bloody diarrhoea, haemorrhage from the 
nose and lungs, asphyxia, paresis, and paralysis, which may be fatal by 
affecting respiration and circulation. 

Immediately after the bite, if the wound is sucked by the human mouth, 
much of the poison can be removed. We may apply the actual cautery, 
make deep incisions, and apply a 5 per cent solution of carbolic acid, but 
this is useless, unless done immediately. 

Internally, alcohol in large amounts is very effectual. The person 
bitten can tolerate an immense amount, and we can only determine when 
to stop its administration by the appearance of the symptoms of alcohol 
intoxication. Antitoxine for snake bites (antivenine) will be available in 
the near future. 

Insect Bites. — Pediculi. — The Pediculus capitis, or head louse, the 
Pediculus corporis, or body louse, and the Pediculus pubis, or crab louse, 
may cause by their bites small hsemorrhagic spots or an urticaria. In cases 
of long standing induration and pigmentation may be produced from the 
bites and from scratching. 

Treatment. — For the head louse, when the condition is bad, it is best to 
cut the hair short, as it is very difficult to destroy the nits. Repeated 
washings in coal oil or turpentine or carbolic acid, 1 to 50, are usually suffi- 
cient. 

For the body louse, the clothing should be baked or steamed in an oven 
or sterilized for several hours. The itching of the skin can be allayed by 
a warm bath containing 4 or 5 oz. of bicarbonate of sodium. A lotion of 
carbolic acid, about .02 per cent with 2 oz. of glycerine, is helpful. 

The pubic louse may be destroyed with ordinary blue ointment or 
white precipitate ointment. The parts should be thoroughly washed two 
or three times a day with soft soap and water. 

Bed bugs may cause in some people very great distress from the local 
poisoning. Bichloride of mercury, kerosene, or sulphur fumigation usually 
destroys them in the cracks of beds or walls, where they secrete themselves. 
They probably can carry an infection from one person to another. 

Myiasis. — This term is given to wounds or scars in which the larva? of 
certain flies develop, making it "living." It is not common in temperate 
climates. The invasion is rare, unless a region is previously diseased. We 
find them in the nose, ears, conjunctivae, vagina (after delivery), etc. They 
can be removed by forceps or by thorough cleansing and antiseptic applica- 
tions. 

The sting of bees, wasps, hornets, and spiders is followed by acute 
pain and considerable local swelling. 

Treatment. — Cold lead water should be applied locally. An incision 
into the swollen tissues is occasionally necessary to relieve tension. 



830 ANAESTHESIA, INTOXICATIONS, MISCELLANEOUS AILMENTS 



DRUG HABITS 

Morphine, cocaine, and chloral, all anodynes and used at first to relieve 
pain, are the most common drugs to which people become addicted. 

The treatment of the morphine habit is to gradually withdraw the drug, 
and it is always best to do this in a trustworthy institution with reliable 
attendants, so that the patient is never alone. As aids, we should give 
good food and plenty of it, and build up the general health. Coffee and 
alcohol in small amounts as stimulants may be helpful. As counteracting 
drugs, dionin, subcutaneously or by mouth, in doses double that of the 
morphine, may be tried. Codeine is also helpful, but the bromides are of 

little use. In collapse we may 
need alcohol and sometimes 
more morphine. Hydrothera- 
peutics is helpful. 

The cocaine habit is very 
difficult to overcome, and its 
victims are most pitiful. It is 
best to take the patient to an 
institution and withdraw the 
drug. It is probably best to 
do it gradually. Great excite- 
ment follows its discontinu- 
ance, and even paranoia. Al- 
cohol and morphine are some- 
times indicated during the 
treatment. 

Chloral may produce se- 
rious symptoms in those ad- 
dicted to it. It may cause 
dyspnoea and even death by 
bronchial effusion. Eruptions 
on the skin are common and 
there is a tendency to skin eruptions upon the slightest provocation. It is 
said also to cause in chronic cases petechia?, ecchymoses, and ulcerations. 
General cedema, profound weakness, and heart failure may result. 
Treatment. — Withdrawal of the drug. 

An emergency poisoning case should form part of the armamentarium 
of the physician. Dr. J. W. Wainright, of New York, has suggested such a 
case with the following contents: 

One stomach tube, one tongue forceps, one mouth gag, one 2-oz. glass 
syringe, one hypodermic syringe. It also contains five 2-oz. bottles of 
magnesium sulphate, of zinc sulphate in 20-grain powders, powdered mus- 
tard, calcined magnesia, and chloroform. The 1-oz. vials contain amyl 
nitrite, alcohol, iron dialyzed, acetic acid, oil of turpentine, and aromatic 
spirit of ammonia. The J-oz. vials contain powdered ipecac, powdered 
opium, potassium bromide, chloral hydrate, and potassium permanganate. 
The hypodermic tablets are of strychnine sulphate, morphine sulphate, 
pilocarpine muriate, apomorphine, hydrochlorate, nitroglycerine, digitalis, 
and atropine sulphate. 




Fig. 225. — Emergency Poisoning Case. 



SEASICKNESS (MAL DE MER) 



831 



ALCOHOLISM 

We recognize two forms of alcohol poisoning, the acute and the chronic. 

The acute intoxication is familiar to every one, but we should always 
try to distinguish it from intracranial haemorrhage and cerebral concussion 
when the patient is comatose. This is exceedingly difficult, as nothing 
is positively diagnostic when the condition of coma exists (see Coma). 

Treatment. — Evacuate the stomach, employ warmth to the extremities, 
apply an ice bag over the heart, use artificial respiration, and give 10 drops 
of aromatic spirit of ammonia in water. 

Chronic alcoholism is sooner or later accompanied by tissue changes 
in different parts of the body. A chronic proliferative inflammation of 
the stomach, liver, blood vessels, heart, and kidneys may finally result. 
Cirrhosis of the liver is a diseased condition frequently due to alcohol. 
Amaurosis, neuritis, epilepsy, tremor, delirium tremens, and general paresis 
may result. Persons who cannot use alcohol moderately must not use it 
at all. In breaking away from alcohol the patient should be allowed to 
take beef tea and drug stimulants, such as strychnine, phosphorus, the 
bromides, and bitter tonics. 

MISCELLANEOUS AILMENTS 

SEASICKNESS (MAL DE MER) 

Sickness caused by the motion of a boat, with its effect upon the brain 
and probably upon the semicircular canals of the inner ear and its accom- 
panying gastrointestinal toxaemia, is a most distressing condition, and one 
most difficult to treat. Many remedies have been advocated, but most of 
them are ineffectual or only partly effective. For several days or a week 
before sailing, it is advisable to put one's self in as good physical condition 
as possible, regulating the diet and looking after the bowels. The diet 
should be plain, easily digestible, and not constipating. For three days 
before sailing from 30 to 60 gr. of sodium bromide a day, in divided doses, 
should be taken, and the use of the drug continued in slightly smaller doses 
during the voyage. It may be used in combination with strychnine, gr. 
-3V ter in die. Chloral, hyoscyamine, and atropine are also helpful. 

During the voyage the diet should not be rich or constipating. One 
should be upon deck as much as possible, facing the wind. A cold bath 
daily and a daily cathartic if necessary are helpful. The prone position, 
with the head slightly lower than the body, gives some relief. Ice, lemon 
juice, or cold champagne or matzoon sometimes allays the nausea. Mental 
suggestion is very helpful. When treatment is unavailing the patient should 
rest in a horizontal position. 

Although no deaths have been actually recorded as due entirely to sea- 
sickness, it has occasionally fatally aggravated hyperemesis gravidarum, 
and not infrequently its effects may be very bad and may last some days 
after a voyage is ended. 

A stateroom amidships on the promenade deck, where the motion is least 
and no kitchen smell is noticed, is advocated. If one looks away upon the 
horizon, and does not watch the motion of the ship or water, one is less apt 
to be sick. 



832 ANAESTHESIA, INTOXICATIONS, MISCELLANEOUS AILMENTS 



MOUNTAIN SICKNESS 

Upon reaching a great altitude, 10,000 feet or higher, one is likely to have 
a headache, nausea, dizziness, and gasping for breath. The throat becomes 
very dry, the thirst is intense, the appetite is lost, and there may be severe 
malaise. The temperature may be slightly elevated. The symptoms may 
last for several days. 

HYDROPHOBIA (RABIES; LYSSA) 

This acute specific disease of certain animals can be communicated to 
man by inoculation, usually through a bite. It is as old as the history of 
medicine and was known to the Greeks as lyssophobia. 

^Etiology. — Most warm-blooded animals are susceptible to this disease, 
but we see it oftenest in the dog, wolf, cat, skunk, and fox. The poison 
is found in the nervous system and in the secretions, particularly the saliva. 
In this country we are usually inoculated through the bite of a dog. The 
saliva of a rabid dog, touching an abrasion, is also likely to infect. Bites 
upon parts uncovered by clothing are most apt to produce the disease. 

The incubation period varies from twenty days to two months, but may 
be as short as two weeks and as long as several months. 

Pathology. — Little is found. Sometimes we find congestion and minute 
haemorrhages in the spinal cord. 

Symptoms. — The symptoms may be divided into three stages: 

Premonitory Stage. — Irritation, pain, or numbness occurs about the 
bite. Depression, melancholia, headache, and loss of appetite follow, with 
irritability, sleeplessness, and a sense of impending danger. The special 
senses are abnormally acute. This stage lasts about a day. 

Spasmodic Stage. — There is a spasm of the muscles of deglutition when- 
ever the attempt is made to swallow. Dyspnoea and the making of odd 
sounds (so called barking) occur when the spasm spreads to the laryngeal 
muscles and those of respiration. Later, these spasms may be produced 
by any afferent stimuli, such as draughts of air, sounds, or even suggestion. 
Any or nearly all of the muscles of the body may be attacked by the spasms. 
Maniacal symptoms may be present. Profuse salivation is usual. The 
temperature may be as high as 103°, although sometimes it is normal or 
subnormal. Prostration becomes more marked after each spasm, and death 
may occur from asphyxia while the patient is in a spasm. Usually this 
stage lasts from one to three days. 

The paralytic stage follows, and may last from six to eighteen hours. 
The patient becomes quiet, the spasms cease, unconsciousness gradually 
develops, the heart's action becomes feeble, and death occurs in syncope. 

Differential Points. — In mania with fear of water there are no tonic or 
clonic convulsions. In tetanus the cause is a wound and not a bite, the 
period of incubation is short, and there is no dribbling of saliva, etc. 

Treatment. — Prophylaxis is our only hope, as when the disease has begun 
it is invariably fatal. Muzzling of dogs should be insisted on. After a 
person is bitten, a ligature should be applied to the proximal side, and 
the wound energetically cupped or sucked by one whose mouth has no 



THE KEEPING OF RECORDS OF CASES 



833 



abrasions or carious teeth or, better, with a suction pump. Immediate 
excision of the wound, with vigorous disinfection, has given good results. 
Preventive inoculation during the period of incubation with virus made 
from the nerve tissue of infected animals, by the process devised by Pasteur, 
has been effectual in reducing the mortality of hydrophobia. After the 
disease has begun, morphine and chloroform may make the patient more 
comfortable. 

SEPTIC WOUNDS AND TRAUMATIC TETANUS 

A clean wound, unless protected by aseptic or antiseptic dressings, may 
become infected from the germs in the air or from unclean or infected 
surroundings, and suppurate. A general or local infection may result, 
which usually demands surgical treatment. 

Tetanus is a wound infection with the bacillus of tetanus (Nicolaier). 
Tetanus of the new-born is fully described in the Paediatric chapter of this 
book. Tetanus in the adult is the result of a' traumatic, usually a contused 
or irregular wound, soiled with earth or foreign matter (toy pistol wounds). 
Preventive treatment, serum therapy, is indicated whenever one encounters 
such a suspicious wound as is described above. Tetanus antitoxine, as now 
furnished, is administered hypodermically in doses of 10 c.c, which may 
be repeated. The wounds should be incised, curetted, and swabbed with 
pure carbolic acid, in addition. 



THE KEEPING OF RECORDS OF CASES UNDER TREATMENT 
AND THEIR ACCOUNTS IN PRIVATE PRACTICE 

The value of keeping careful records of all cases treated may be demon- 
strated in many ways. Not only does it give an added interest while the 
case is under treatment, but a written account of the course of the disease, 
with its interesting points put down as they appeared and the medication 
prescribed, is important both as a means of bringing the case quickly before 
the mind and as a source of valuable data in case of a question of law. 

Any system, to be entirely successful, must be economical of space and 
yet provide an arrangement which makes it possible to put down all points 
connected with the case, whether they relate to medication or any sudden 
change in the condition. The record should not be too brief, or it will lose 
all value when studied afterward. It must be just brief enough to be 
entirely comprehensive and to include all points connected with the case as 
they arise. 

In hospitals or in private practice where a trained nurse is in attendance, 
the opportunity for keeping a complete record is provided by the systems 
in use, but in private practice, where the physician can depend only upon 
himself, another method must be devised. 

The following system, which combines not only the recording of the 
history and the course of the disease and its treatment, but also a ledger 



Name 

Address Age 

Date Diagnosis 

Previous History 



Present History 



Fig. 226. — Case Record. 



Name 


Date 


T 


P 


R 


Treatment and Remarks 





























































































































































































































































Fig. 227. — Case Record. 



Name 




Jan 


Peb, 


tfch 


Apr 


4ay 


Jne 


Date 


Due 


Paid 


Bal'ce 


1 












? 










o 






















7> 






















4 












































6 






















7 






















.8 






















q 






















in 






















11 






















1?, 






















13 






















14 






















15 






















16 






















17 






















18 






















19 






















?,n 












































.22 






















23 






















24 


































































?<7 






















26 






















P-9 






















30 
























,31 

























































































Fig. 228. — Day-Book and Ledger. Size 4x7. 
The other side is similar, except that the columns are marked from July to December. 



THE KEEPING OF RECORDS OF CASES 



837 



for the account of each patient, is intended for the use of physicians among 
their patients where no trained nurse is employed, and where he himself is 
taking the temperature, pulse, and respiration and is doing all the nursing 
outside of the ordinary care of the patient. The , o called card system is 
employed, and there is provided a card for the recording of the history of 
the case, both as to the condition of health and as to the diseases in the past 
and the symptoms of the present illness. The card is ruled on both sides, 
so that the history may be carried over on to the back (Fig. 226). 

Another card, "the bedside notes," is provided, which is so ruled as to 
make it possible to jot down upon each visit the date, hour, temperature, 
pulse, and respiration, the medication ordered, the condition of the patient, 
and any other notes that may be of value (Fig. 227). This card may be car- 
ried in the pocket or in the physician's bag and referred to when the visit 
is made, or it may be left in the patient's room and taken away at the last 
visit. These two cards are all that are necessary to keep a full record of 
each case, and if the notes are written down at the bedside, they are thereby 
rendered authentic and make a valuable history of the case. A tin box 
of a proper size to fit the cards is necessary for the filing of the completed 
records and for their easy reference. This box should contain a set of 
alphabetical index guide cards, and each history with its set of bedside 
notes should be placed behind the guide card bearing the initial letter of 
the patient's name. Subsequent histories and notes of patients with the 
same initial letter are placed behind this. This makes a complete, compact 
arrangement, and if the tin box is japanned or is made of quartered oak, it 
makes a very acceptable bit of office furniture. 

To this system may easily be added the keeping of the account of each 
patient, thereby doing away entirely with the bulky day book and ledger 
at present used. A card is provided similar to the one shown in Fig. 228. 
Both sides of the card are used, the one side for the accounts of the first 
six months, and the other for the last six months of the year. It is so ruled 
that the fee for each visit may be written down. At the end of each month 
the amount is summed up at the bottom. On the right half of the card are 
ruled spaces for the credit side of the account. The first space is for the 
noting of the date upon which the bill is sent out, the amount of the bill 
up to that date being placed in the second column. When the bill is paid, 
the date is placed in the first column and the amount paid in the third 
column. If any balance remains due, this is placed in the last column on 
the same line with the amount paid. When the next bill is sent out, this 
balance is added to any new account and placed in the second, or " Due," 
column. If the account is entirely paid up, no figure will appear in the 
balance column. The card will contain the account of each patient for one 
year, and is placed in the box directly in front of the history card. 

This system makes the keeping of accounts concise and complete, for 
it not only places every item in plain view on one page, but it does away with 
all books. The small book now used for the recording of each visit or pre- 
scription, which record is later copied into a day book, is made unnecessary 
by this system, for the bedside note card is the index for each visit made, the 
day and hour being written there. The fee for the visit is placed in the 
column corresponding to the day and month, and at the end of the month 



838 ANAESTHESIA, INTOXICATIONS, MISCELLANEOUS AILMENTS 



these are summed up. When payments are made, they are placed on the 
credit side of the card. This card, therefore, becomes a combined day 
book and ledger, and one card serves the purpose of three books. 

Therefore, the history of the disease, the record of its symptoms, course, 
and treatment, and the patient's account are brought compactly under one 
head, and, if arranged alphabetically in a tin or oak box, make a perfect 
system, accurate and easily available for examination. 



i 



INDEX 



Abdomen, auscultation of the, 270; inspec- 
tion of the, 270; palpation of the, 509; 
tapping of the, under anaesthesia, 392. 

Abortion, 530; prognosis of, 530; symptoms 
of, 530; threatened, 530; treatment of, 
530; unavoidable, 530. 

Abscess, alveolar, 255; appendicular, 473: 
chronic, 534, 762 ; differential diagnosis in, 
762; mediastinal, 468; pathological factors 
of, 318; pelvic, 526; perinephritic, 483; 
symptoms of, 483, 484; periurethral, 494; 
retropharyngeal, nasal intubation in. 197, 
198; retropharyngeal, 197; symptoms, 
diagnosis, and treatment, 197; serous, 
405; spinal tuberculous, 573; subphrenic, 
331; suburethral, 522; tropical liver, 318. 

Abscess of bone, pyaemic, 536. 

Abscess of joints, 546. 

Abscess of the brain, 759, 761; aetiology of, 
761 ; pathology of, 761 ; symptoms in acute 
cases of, 761 ; treatment of, 762. 

Abscess of the breast, 92. 

Abscess of the liver, 318, 403; aspiration in 
doubtful cases of, 318; symptoms of, 318; 
treatment of, 318. 

Abscess of the lung, 432; diagnosis of, 432; 
prognosis of, 432; treatment of, 432. 

Abscess of the vulvovaginal glands, 522. 

Abscess of thymus gland, 170. 

Absorption and motility (of the stomach), 
34. 

Acetanilide, 65. 
Acetonsemia, 370. 

Acetone, in the urine of diabetes mellitus, 21 ; 

test for, in the urine, 22. 
Achillodynia, 589. 
Achondroplasia, 98. 
Achorion Schoenleinii, 784. 
Acne, albida, prognosis and treatment of, 

771; cachectieorum, 771; punctata, 771; 

punctata nigra, 771; rosacea, prognosis 

and treatment of, 771 ; sebacea, 772. 
Aconite poisoning, treatment of, 827. 
Acrania, 765. 

Acromegaly, 772; aetiology of, 672; pathol- 
ogy of, 672 ; symptoms of, 672 ; treatment 
of, 673. 

Actinomycosis, of bone, 539; of the mouth, 
247 ; pulmonary, 445 ; skin, 782 ; treatment 
of, 783. 

Addison's disease, 670; setiology of, 670; 
course of, 671 ; diagnosis and prognosis of, 
671; heart weakness in, 671; prostration 

54 



in, 671; symptoms in, 671; treatment 
of, 672. 
Adenia, 380. 

Adenoid growths and their removal, 194- 
197. 

Adenoids, in children, 194-197; before and 
after operation, 196; conditions which 
have been found to simulate, 196, 197; 
operation for, 195; possible and avoidable 
traumatism during operations for, 196: 
removal of, in laryngismus stridulus, 212; 
removal of, under ether, 196. 

Adrenalin, chloride in oedema, 181; solution 
for local anaesthesia, 430. 

Agglutinins, 54. 

Ailments, genitourinary, 12 ; mental and 
nervous, 12; miscellaneous, 830, 832, 833; 
of the mouth in children, 126, 127. 

"Air hunger," 372. 

" Albadermine," 803. 

Albinism, 772. 

Albolene, atomizer for, 77, 416. 
Albuminuria, in infective fevers, 602, 603; 

relation of, to nephritis, 472; remarks on, 

471. 

Alcohol, as a stimulant, 71, 72; poisoning, 

treatment of, 827, 831. 
Alcoholism, acute and chronic, treatment of, 

831. 

Alimentation, rectal, 59; rectal, in cerebro- 
spinal meningitis, 223. 
Alkalies, treatment of poisoning by, 826. 
Alkaline treatment for rheumatism, 551. 
Allingham's operation for haemorrhoids, 308. 
Allochiria, 795. 
Aloin test for blood, 25. 
Alopecia, 797; treatment of, 797. 
Amaurosis, 812. 
Amblyopia, 812. 

Amenorrhcea, 516; treatment of, 517. 
Ammonia poisoning, treatment of, 826. 
Amnion, dropsy of the, 406. 
Amoeba, dysenteriae, 30; intestinalis, 300. 
Amyelia, 766. 

Amygdalitis, catarrhal, 424; follicular, 424, 
425; lacunar, 424. 

Anaemia, 369, 796; aetiology of, 674; balloon 
treatment of, 374; blood in, 45-46; causes 
of, 375; course of, 674; differential diagno- 
sis of, 674; essential, 374; following diph- 
theria, 179; idiopathic, 374; in cardiac 
disease, 354; lymphatic, 380; pallor of, 
769; pathology of, 674; pernicious pro- 
839 



840 



INDEX 



gressive, diagnosis and prognosis of, 375; 
pernicious progressive, pathology of, 374; 
pernicious progressive, symptoms of, 374; 
pernicious progressive, treatment of, 375; 
prognosis and treatment of, 382. 

Anaemia, secondary, pathology of, 375; sec- 
ondary, symptoms of, 376; secondary, 
treatment of, 376 ; secondary to other dis- 
eases, 375; simple, 372; splenic, 381, 674; 
symptoms of, 674; temperature in, 376; 
toxic, 375; treatment of, 674. 

Anaesthesia, general, 823; laryngeal, 428; 
local, 824; of the pharynx, 428; prelimi- 
naries to, 824 ; requisites for, 824 ; Schleich's 
infiltration, method of, 825; spinal, 825; 
tact'Je, 795; vomiting in, 824. 

Anaesthetics, administration of, 824. 

Analgesia, 795. 

Anasarca, 388; general, 403; sweating in, 
389. 

Anchylostomum duodenale, 31. 
Anelectrotonus, 682. 
Anencephaly, 765. 

Aneurysm, 362; aortic, 362; aortic, rational 
signs of, 362 ; of the abdominal aorta, 327, 
363 ; of the splenic artery, 363 ; symptom- 
atic management of, 363; treatment of, 
363. 

Angeiokeratoma, 789. 

Angeioma, cavernous, 789; simple, 789; su- 
perficial and cavernous, 95. 
Angeioneurosis, 734. 

Angina, false, in gout, 646; hysterical, 358; 
Lodovici, 425; mild true, in valvular dis- 
ease, 359. 

Angina pectoris, 359; differential points, 
359 ; spurious, 358 ; treatment of, 359. 

Anguillula intestinalis, 300. 

Anidrosis, 734; prognosis and treatment of, 
770. 

Ankylosis of the spinal column, 553. 
Ankylostomiasis (hook worm disease), 299, 

300 ; treatment of, 300. 
Anomalies, of pigmentation, 772; of sensory 

function, 767; of the brain, 765; of the ear. 

eye, limbs, trunk, etc., 767. 
Anorexia, 263; men talis, 263. 
Anosuria, 427. 
Antidotes, 825. 
Antifebrin, 65. 

Antimony poisoning, treatment of, 826. 

Antipyretic measures, 64. 

Antipyrine, dose, 65. 

Antisepsis, intestinal, 303. 

Antitoxine, indications for, in diphtheria, 

175, 176; tetanus, 833. 
Antitoxines, 54. 
Anuria, 476. 

Anus, imperforate (in infants), 102. 
Aorta, aneurysm of the, 327, 362, 363. 
Aphasia, remarks on, 680. 
Aphonia, 226. 

Apoplexy, cerebral, 695; aetiology of, 695; 
diagnosis and prognosis of, 696; pathol- 
ogy of 695, symptoms of, 695; treatment 
of, 696. ' 

Apoplexy, pulmonary, 432 



Apoplexy, serous, in hydrocephalus, acute, 
398. 

Apoplexy, spinal, 763, 764; pathology of, 

698; prognosis of, 698; symptoms of, 698; 

treatment of, 698. 
Apparatus for infusion and hypodermocly- 

sis, 72; necessary for examination of 

urine, 17. 

Appendicitis, acute, symptoms of, 293; 
chronic, and movable kidney, 484; com- 
bined with typhoid fever, 294; definition 
and varieties of, 293; differential points 
in, 294; examination of the patient in, 
292; non-operative treatment in, 295; 
palpation in, 292; prognosis and treat- 
ment in, 294, 295; pulsation in, 293. 

Appetite, disorders of the, 263. 

Argyll Robertson pupil in locomotor ataxia, 
702. 

Argyria, 769. 

Arrhythmia, 356, 357; treatment of, 357. 

Arsenic poisoning, treatment of, 826. 

Arteries, diseases of the, 359. 

Arteriosclerosis, 346, 360; diet and medica- 
tion in, 360. 

Artery, aneurysm of the splenic, 363. 

Arthritis, 546; acute, 546; acute, treatment 
of, 546; gonorrhceal, 148; symptoms and 
treatment of, 547; neuropathic, 678; neu- 
ropathic (Charcot's joint), 559; treatment 
of, 559; rheumatic, 148, 551, 552; rheu- 
matic, chronic, 556; septic, acute, 546; 
syphilitic, 556. 

Arthritis deformans, aetiology of. 552; and 
gout, differential points between, 648; 
and rheumatism, chronic, differential diag- 
nosis between, 555; atrophy of muscles 
in, 553; baths in, 555, 556; course of, 
554; definition of, 551; deformities result- 
ing from, 554; differential diagnosis of, 
554; drugs in, 556; general progressive or 
polyarticular form of, 553 ; local treatment 
of, 556; massage for, 556; onset of, 553; 
partial or monarticular form of, 553; 
pathology of, 552; prognosis of, 554; pro- 
phylaxis of, 555; termination of, 554; 
treatment of, 555, 556. 

Ascaris lumbricoides, 30, 31, 148, 248. 

Ascites, 328, 391; differential points, 391; 
history of, 391 ; management of, 391 ; oper- 
ative treatment of, 318, 393; plus oedema, 
tapping in, 391. 

Aspergillus glaucus, 783; niger, 783. 

Aspermatism, 506. 

Asphyxia, from tongue swallowing, 247; in 
the new-born, 87; local, 734, 796. 

Aspiration, from the patient's standpoint, 
397; in pericardial effusion, 396, 397; of 
the chest, 394, 395. 

Aspirator, heat vacuum, 396. 

Asthenopia, 812. 

Asthma, bronchial, differential points of, 
458; digestive tract in, 459; hypnotism in, 
460; neurotic element in, 460; powder for 
(to be burned under an improvised tent), 
459; suggestion therapy in, 460; symp- 
toms of, 457, 458 ; treatment of an acute 



INDEX 



841 



attack of, 458, 459; urogenital tract in, 
459. 

Asthma, Charcot-Leyden crystals in, 36. 

Asthma in bronchopneumonia, acute, 157. 

Asthmatics, change of climate for, 460. 

Astigmatism, 822. 

Asymmetry, cranial, 105. 

Ataxia, diagnosis of, 703; Friedreich, 704; 
hereditary, 704. 

Ataxia, locomotor, 742; aetiology of, 701; 
bladder and rectum symptoms in, 702; 
crises of, 702, 703; diagnosis of, 703; eye 
symptoms in, 702; impairment of muscu- 
lar sense in, 702; onset of, 703; pain and 
loss of tendon reflex in, 701, 702; pares- 
thesia in, 701; paralysis of, 703; pathol- 
ogy of, 701; prognosis of, 703; symptoms 
of, 702, 703; treatment of, 703. 

Atelectasis, congenital, in the new-born, 93. 

Atheroma, 360. 

Athetosis, 678. 

Atkinson's table of nutrients and calories 

of different people, 233. 
Atony of the bladder, 487. 
Atresia, 102-104; vagina? hymenalis, 104. 
Atrophica, 771. 

Atrophy, infantile, 142; of bone, 541; of 
bone, treatment of, 541; of muscles, 562; 
of muscles in arthritis deformans, 553; of 
the liver, acute yellow, 316; of the thy- 
mus gland, 142; optic, 820; progressive 
hereditary muscular (Charcot-Marie type), 
699 ; progressive hereditary muscular, per- 
ineal type, 699; spinal progressive mus- 
cular, pathology, prognosis, symptoms, 
and treatment of, 699. 

Aurae, auditory, of epilepsy, 722; ocular, of 
epilepsy, 722; olfactory, of epilepsy, 722; 
psychical, of epilepsy, 722. 

Auscultation, in bronchopneumonia, 436; 
in pleurisy with effusion, 163; in pneumo- 
thorax, 465; in tuberculosis, 450; of the 
abdomen, 270; of the stomach, 270. 

Autoscopy and tracheoscopy, 412. 

Azoospermatism, 506. 

Babcock's milk test, 118. 
Babies, blue, 100. 
Baby, how to hold the, 90. 
Bacelli's sign, 162. 

Bacillus anthracis, 784; coli communis, 29; 
colon, 41; comma, 29; comma, of Koch, 
632; diphtherias (morphologically), 39; 
dysenteriae, 29, 125; Klebs-Loeffler, 39, 
41; lactis aerogenes, 29; of influenza, 37; 
paratyphoid, 48; pestis, 641; pyocyaneus, 
41; smegma, 37; tubercle, 29, 30, 37; 
typhosus, 29; typhosus of Eberth, 616. 

Bacteria and protozoa in faeces, 29. 

Backache, causes of, 563 ; treatment of, 563. 

Baldness, treatment of, 797. 

Balloon treatment of anaemia, 374. 

Balneotherapeutics, 65, 69. 

Band, scratch, of Lorenz, 574. 

Banting and Ebstein systems of diet, 239. 

Barbadoes leg, 785. 

Barley water in infant feeding, 116. 



Bartholin's glands, inflammation and cysts 
of, 523. 

Bath, cold, 66; douche, 66; hot, 67; hot-air, 
66; mustard, 67; permanent, 67; Russian, 
67; sheet, 68; sponge, 67; Turkish, 66; 
vapor, 66; warm and cold, 66, 68. 

Bathing, infant, 89. 

Baths, 65-68; in valvular heart lesions, 353. 
Bed, Feely invalid, 85; grapple, 84; Hebra's 

water, 67. 
Bedsores, treatment of, 772, 773. 
Bed wetting, 213. 
Beef peptonoids, 58. 
Beef tea, peptonized, 238. 
Belching of gas, 73. 

Belladonna poisoning, treatment of, 827. 

Bell's palsy. See under Palsy. 

Belly, pot, of rhachitic children, 144. 

Beri beri, 662, 713. 

Beverages, stimulants and, 236, 237. 

Bier's treatment in tuberculosis of the 

joints, 558. 
Bile ducts, diseases of the, 321. 
Bile in the urine, 22. 
Bile pigment in sputum, 36. 
Bilharzia haematobia, 492. 
"Bilious attacks," 302. 
Birth marks, 95, 791. 
Birth palsies, 101. 
Bites, insect, treatment of, 829. 
Black death, 641. 
Blackheads, 771. 

Bladder and rectum symptoms in locomotor 
ataxia, 702. 

Bladder, atony of the, 487; diseases of the, 
321; exstrophy of the, 486; gall, dropsy of 
the, 404; gall, inflammation (acute) of the, 
321 ; inversion of the, 486 ; irrigation of the, 
488; irritability of the, 486; paralysis of 
the, 487; prolapse of the, 524; rupture of 
the, 486; stone in the differential points 
in, 489; stone in the, examination for, 
489 ; stone in the, prognosis of, 489 ; stone 
in the, treatment of, 489; tumor of the, 
473; urinary, inspection of the, 486. 

Blastomycetae, 782. 

Bleeders, 384; treatment of, 384, 385. 

Bleeding of the gums, 243; in infants, 126. 

Blepharitis, treatment of, 816. 

Blepharospasm, 814, 817. 

Blindness, half, 812; night, 812; snow, 812. 

Blisters, fever, 776; water, 779. 

Blood, aloin test for, 25; casts, 25; circula- 
tion of the, massage for, 597; conditions 
of the, 368; counting, cells by method 
of Einhorn and Laporte, 43, 44; in stools, 
differentiation of, 28; in urine, 25; normal, 
leucocytes in, 369; obtaining number of 
red corpuscles in the, 43; plasma, 369; 
plates, 369; slides, preparation of, 44. 

Blood examination, 15, 42; counting the 
cells in, 42, 43; diseases requiring, 45-50; 
Gower's method of, 42 ; where to puncture 
for, 43. 

Bloodless method of reducing dislocation of 
hip, 584. 

| Blood poisoning. See Septicaemia. 



842 



INDEX 



Bloody method of reducing dislocation of 

the hip, 586. 
Blue babies, 100. 

Boas and Ewald's test breakfast, 268. 
Bodies, rice, 406, 567: Wormian (in infants), 

106. 
Boils, 785. 

Bone, abscess, pya?mic, 536; actinomycosis 
of, 539; atrophy of, 541; hypertrophy of, 
541; inflammation, acute, 535; inflamma- 
tion, chronic, 536; new formation of, 534; 
pathology of inflammation in, 533, 534; 
rider's, 561 ; structure, examination of, 
with Rontgen rays, 535; syphilis of, 538, 
539; syphilis of, hereditary, 539; tuber- 
culosis of, 536; tumors, benign, 539; tu- 
mors, malignant, 540. 

Bones, dislocations of, 542; fractures of, 
542; injuries of, 542. 

Bothriocephalus, 30. 

Bottle, ignition vacuum, for aspirating 
fluids, 397. 

Bowel, antisepsis, 303; dilatation of the, 
congenital and acquired, 288 ; obstruction, 
site of the, 296 ; obstruction, treatment of, 
296, 297. 

Bradycardia, 356, 358. 

Brain, abscess of the, 761, 762; acute soften- 
ing of the, 695; anomalies of the, 765; 
disease of the base of the, 681; gummata 
of the, 750; miscellaneous lesions in the, 
751 ; softening, 760; syphilitic deposits into 
the, 750; tumors, of the, 757-760; wet, 
397. 

Brain compression, artio'ogy of, 754; diag- 
nosis of, 755; in acute leptomeningitis, 
740; localizing symptoms of, 756; prog- 
nosis of, 756; symptoms of, 755. 
rain concussion, diagnosis of, 754 ; pathol- 
ogy of, 753; prognosis of, 754; stage of 
collapse, of convalescence, and of reaction, 
753, 754; symptoms of, 753; treatment of, 
754. 

Breast, abscess of, 91, 92; caking of, 91; in- 
flammation of, in nursing, 91; milk, 40. 
Breasts of infants, 94; angeioma of the, 94. 
Breath, foul, 250. 

Bright's disease, chronic, 479; chronic, 
cramps in the legs in, 563; chronic, diet 
in, 479; enteroclysis in, 479; gouty form 
of, 644; kidney decapsulation in, 472; 
prognosis in, 478; remarks on, 478; sur- 
gical treatment of, 48 1 ; symptoms in, 
478; treatment in, 479. 

Bright's disease and movable kidney, 484. 

Bromide of sodium in heart palpitation, 357. 

Bromidrosis, prognosis and treatment of, 
770. 

Bronchiectasis, 446; symptoms of, 446. 

Bronchitis, acute, 434; acute (in children), 
152; clinical feature of, 152; acute, diag- 
nosis of, 434; acute, symptoms of, 434; 
acute, treatment of, 434; capillary, 153, 
435; capillary (in children), predisposing 
factors of, 154; chronic, 442; chronic, 
terebene and terebene hydrate in. 76; 
chronic, treatment of, 443; chronic, simple, 



clinical varieties of, 442; chronic, simple, 
symptoms of, 442; differential points of, 
434; fibrinous, chronic, diagnosis of, 443; 
fib) 'inous, chronic, prognosis of, 443; 
fibrinous, chronic, symptoms of, 442; 
putrid, 442 ; subacute, 434 ; subacute, 
differential points, 434; subacute, prog- 
nosis of, 434; subacute, symptoms of, 
434; subacute, treatment of, 434. 
Bronchocele, 105. 

Bronchopneumonia, 446; clinical varieties 
of, 436; differential points of, 436; prog- 
nosis of, 436; prophylaxis of, 436; treat- 
ment of, 436; acute, temperature in, 435; 
acute fibrinous, treatment of, 438; diph- 
theritic, 438; diphtheritic, treatment of, 
438; in children, 153-157; tuberculous, 
acute, differential points of, 437. 

Bronchostenosis, 426, 427. 

Bubo, 502. 

Bunions, 790; suppuration and ulceration 

of, 790; treatment of, 790. 
Burn of the eye, lime, 816. 
Burns of the conjunctiva. 816; treatment of, 

773. 

Bursse, dropsy of, 406. 
Bursitis, acute, and chronic, 560. 

Cachexia, 11. 

Cachexia, malarial fever, 613. 

Caking of the breast, 91. 

Calcium oxalate, phosphate, and sulphate 

in stools, 29. 
Calculi, 51, 52, 322, 475; in the nose, 422; 

prostatic, 52; renal, 51; ureteral, 51; 

urethral, 52; vesical, 31; with hair at- 
tached, 52. 
Calculus, pancreatic, 328; salivary, 52; 

urethral, treatment of, 494. 
Calories, list of, as an aid in selecting a diet, 

234; per pound, 233; required in food per 

day, 232. 

Camphor as a diuretic, 75; oil of, in oedema, 
389. 

Cancer, epithelial, 793; of the biliary ap- 
paratus, 324; of the body of the uterus, 
530; of the cervix uteri, prognosis of, 529; 
of the cervix uteri, treatment of, 529; 
of the liver, differential points of, 319; of 
the liver, symptoms of, 319; of the liver, 
treatment of, 320; of the oesophagus, 259; 
of the peritonaeum and omentum, 332; 
of the stomach, differential points of, 280, 
281; of the tongue, 248; primary, 319; 
secondary, 319. 

Cancrum oris, 245. 

Canities, acquired, 797; congenital, 797; of 

the hair, 797. 
Cannula for irrigation of the stomach, 62. 
Cannula T, 60, 62. 
Caput succedaneum, 97. 
Carbohydrates, 231. 

Carbolic acid poisoning, treatment of, 826. 
Carbuncles of diabetes, 654. 
Carbunculus, 784, 785. 
Carcinoma, 467, 793; cutis, 793; of the 
pleura, 467; of the rectum, diagnosis of, 



INDEX 



843 



295; of the skin, 793; pigmentosum, 793; 

treatment of, 793; tuberosum, 793. 
Carcinomata, 529; of the brain, 757. 
Carcinosis, 320. 
Cardialgia, 282. 

Cardioptosis, weak heart from, 344. 

Caries, dental, 251 ; of the attic and choleste- 
atoma, 809. 

Cartilages semilunar, displacement of the, 
559; symptoms and treatment of, 559. 

Caruncles, urethral, 494. 

Case, emergency poisoning, 830. 

Castration, for osteomalacia, non-puerperal, 
543; on women, effects of, 520. 

Casts, blood, 25; epithelial, 25; fibrinous, 
in sputa, 35; granular, 25; hyaline, 24; 
pus, 25; waxy, 25. 

Catalepsy, 729; artificial, 732. 

Cataphoresis, 682. 

Catarrh, acute, of the bile ducts, 321 ; acute 
tracheal, 415; chronic atrophic, 305; 
chronic gastric, 274; chronic gastric, diet 
and treatment of, 275, 276; dry, 442; 
hypertrophic, 305; laryngeal, chronic, 
417; nasal, chronic, 415; nasal, chronic, 
causes and symptoms of, 416; rectal. 
289, 304; simple acute, 304. 

"Catching cold," 151, 413. 

Catelectrotonus, 682. 

Catheter, Kemp's double current, 64. 

Catheterism, 475. 

Catheters, various kinds of, 476. 

Caustic, lunar, treatment of poisoning by, 
826. 

Cell diagnosis, 52. 

Cells, blood, counting of, 43, 44, 46; mast, 
369. 

Cephaloematoma, external, 97; internal, 97. 

Cephalalgia. See Headache. 

Cerebrospinal fluid, 53, 407. 

Cerebrospinal meningitis. See Meningitis. 

Cerumen, impacted, 808; treatment of, 808. 

Cervix, laceration of the, 524. 

Cervix uteri, cancer of the, 529. 

Chafing of the skin, 777. 

Chain, side, hypothesis of, 53. 

Chalazion, treatment of, 816. 

Chancre, indurated, mature, 498; soft, 501; 
prognosis and treatment of, 501; syphi- 
litic, 498. 

Chancroid in the female, 502; treatment of, 
501. 

Change of life, 518. 
Chapin dipper, 121. 

Charcot-Leyden crystals in asthma, 36; in 
stools, 29. 

Charcot's joint in locomotor ataxia, 703; 

treatment of, 559, 560. 
Cheiragra, 643. 

Chemicals used in examination of urine, 18. 
Chemosis, 402. 

Chest, exploratory puncture of the, 394. 
Chickenpox, 201 ; symptoms and treatment 
of, 201. 

Chickenpox and discrete smallpox, distin- 
guishing characteristics between, 638. 
Chilblain, 774. 



Chill of malaria, 611. 
Chills of fever, 13. 

Chloasma, 772; idiopathic and symptomatic, 
772. 

Chloral habit, treatment of, 830. 

Chloral hydrate poisoning, treatment of, 826. 

Chlorides in the urine, 23, 24; quantitative 
test for, 23. 

Chloroform as an anaesthetic, 823. 

Chlorosis, aetiology of, 373; diagnosis and 
prognosis of, 373; pathology of, 373; 
symptoms and treatment of, 372. 

Cholsemia, 370. 

Cholera, 29, 137, 632; dry, 633. 

Cholera asiatica, 29, 137, 632; collapse, stage 
of, in, 633; definition of, 632; diagnosis of, 
633; lavage for vomiting of, 634; prog- 
nosis of, 633; stools of, 633; symptoms of, 
633; treatment of, 633. 

Cholera infantum, 135, 136, 137; period of 
convalescence in, 138; stimulation in, 137; 
stomach washing in vomiting of, 137. 

Cholera morbus, 289 ; symptoms, treatment, 
and prognosis of, 289. 

Cholera sicca, 633. 

Cholerine, 633. 

Cholesterin crystals, 30. 

Chondrodystrophy fcetalis, 99. 

Chondromata, 540. 

Chordee, 493. 

Chorea (St. Vitus's dance), 215; clinical 
varieties of, 215; management and treat- 
ment of, 215, 216; symptoms and course 
of, 215. 

Chorea, habit, 691. 

Chorioiditis, 819. 

Chromidrosis, prognosis and treatment of, 
770. 

Chvostek's symptom, 212. 
Chylopericardium, 342. 
Chyluria, 492. 
Cicatrix, 789, 790. 

Circulation, disorders of the, 359; influence 
of a weak heart on the, 335; massage for, 
597. 

Circulatory failure and stimulation, 160. 

Circulatory system, the, 333-408. 

Cirrhosis of the kidney, 480. 

Cirrhosis of the liver, aetiology of, 317; symp- 
toms and diagnosis of, 317; treatment, 
local, 317; operative, 318. 

Cirrhosis of the lung, 446 ; causes of, 
446. 

Citrophen, 65. 

Clamp and cautery operation for haemor- 
rhoids, 308. 

"Clap," 502; complications of, 505; instruc- 
tions to those having, 502. 

Classification of mental disturbances after 
Kraeplin and Meynert, 733. 

Clavus, 790; hystericus, 728. 

Cleft palate, 102. 

Cleidagra, 643. 

Clinical aspect of hypertrophy and dilata- 
tion of the heart, 336. 

Clinical examination of the stomach con- 
tents, 31, 32. 



844 



INDEX 



Clinical pathology of the stomach and in- 
testine, 262. 

Clipper, tonsillar, use of Gleitsmann's, 426. 

Club foot, 104; paralytic, 592; paralytic, 
symptoms and treatment of, 590, 59 i. 

"Clumping," 47. 

Cocaine habit, treatment of, 830. 

Coccygodynia, 311, 312, 686. 

Codeine habit, treatment of, 830. 

Coil, cold, 68. 

Cold, catching, 151, 413. 

Colds, 150, 151, 414; predisposing causes of, 
414; prophylactic measures against, 414; 
symptoms of, 414; treatment of, 152, 414. 

Colic, 282; and vomiting (of infants), 129; 
biliary, pain of, 488; gallstone, 322, 612; 
gallstone, complications and sequelae of, 
323; gallstone, differential points in, 323; 
gallstone, fever and pain in, 322; gallstone 
impaction in the common duct in, 323; 
gallstone, pain in, 282; in the new-born, 
93; lead, pain of, 282; menstrual, 517; 
mucous, pain of, 282, 287; renal, pain of, 
282, 323. 

Colitis, 289; chronic mucous, 141. 

Collapse, acute, 338, 339, 355 ; treatment of, 
339. 

Colon, dilatation of the, 287; flushing the, 

63, 71; inflation of, 64. 
Coma, 716, 717, 718, 722; diabetic, 654, 655; 

differential diagnosis and treatment of, 

718, 719; opium and morphine, 719; stage 

of, in epilepsy, 722; table distinguishing 

causes leading to, 718, 719. 
Comedo, prognosis and treatment of, 771. 
Comma bacillus of Koch, 632. 
Compression of the brain, diagnosis of, 755; 

in acute leptomeningitis, 740; symptoms 

of, 755, 756; treatment of, 756. 
Concrements, oxalic, 470; phosphatic, 470; 

salivary, 249; urinary, 469, 475. 
Concretions, 425, 488; in the genitourinary 

tract, 488; tonsillar, 425. 
Concussion of the brain, diagnosis of, 754; 

pathology of, 753; prognosis of, 754; 

stage of collapse, of convalescence, and of 

reaction in, 753, 754; symptoms of, 753; 

treatment of, 754. 
Concussion of the spinal cord, 763. 
Conditions, psychical, 680. 
Congelatio, prognosis and treatment of, 

774. 

Congenital defects, 335. 

Congestion, depletion, local, for relief of, 79; 
hepatic, prescription for, 354; hypostatic, 
431, 432; of the kidneys, 477, 478; of the 
liver, 316; passive, 431. 

Congestion, pulmonary, aetiology of, 431; 
clinical features of, 431 ; physical signs of, 
431; prescription for, 354; symptoms of, 
431, treatment of, 431. 

Conjunctiva, foreign bodies in the, 816; 
wounds of the, 816. 

Conjunctivitis, general treatment of, 818; 
diphtheritic, 818 ; gonorrhceal, 818; pseudo- 
membranous, 178; purulent, 818; simple, 
817. 



Constipation, 283; causes of, 283; in the 
new-born, 92, 129; treatment of, 284. 

Consumption, 446; galloping, 437; hasty, 
437. 

Contracture of muscle, 562. 

Contractures of fasciae, 568. 

Contusion and laceration, of the brain, 751; 
diagnosis of, 751; prognosis and treat- 
ment of, 752; symptoms of, 751; of the 
spinal cord, 763. 

Convalescence, diet in, 59; general treat- 
ment during, 82. 

Convalescents, tonics for, 82, 83. 

Convulsions, 678, 716; clonic, 716; in in- 
fectious fevers, 214; of hysteria, 728; puer- 
peral, diagnosis of, 720; puerperal, prog- 
nosis of, 720 ; puerperal, prophylactic 
treatment of, 720, 721 ; puerperal, pulse in, 
717; puerperal, symptoms of, 717; puer- 
peral, temperature in, 717; symptomatic 
management of, in children, 214; treat- 
ment of, 214. 

Convulsions, tonic, 716. 

Copper salts, treatment of poisoning by, 
826. 

Coprolalia, 691. 
Cor adiposum, 345. 

Cord, spermatic, 495, 496 ; spinal, injuries 
of the, 763; spinal, malformations of the, 
766; spinal, wounds of the, 763. 

Cords, trembling of the vocal, 429. 

Cornil's myelocytes, 369. 

Corns, treatment of, 790. 

Corrosive sublimate, treatment of poisoning 
by, 826. 

Corset, straight front, as a support to 
abdomen for movable kidney. 484. 

Coryza, 152; hay fever, 427; syphilitic, in 
children, 419. 

"Cough, croupy," 181; early, of tuber- 
culosis, 450; mixtures, 75, 76; nervous, 
429 ; of tuberculosis, 456 ; reflex, 429 ; 
whooping, see Whooping Cough. 

Coughing, centre for the act of, 409. 

Coughs, 150, 151; throat, of children, 153. 

Counterirritants, 78, 79. 

Counting slide for blood cells, 43. 

Courvoisier's law, 322. 

Coxa vara, 586; aetiology, 586; diagnosis of, 
587; symptoms of, 586; treatment of, 
587; when operation is indicated for, 587. 

Coxitis, 294. 

Crab louse, 782. 

Cramp, 716; ballet dancers', 692; teleg- 
raphers', 692; treatment of, 692, 693; 
various forms of, 692; writer's, 691; 
writer's, prognosis of, 692; writer's, symp- 
toms of, 692. 

Cramps in the legs, 563; stomach, 282. 

Cranium puncture, 407. 

Cream, evaporated, 116. 

Cream testing outfit, 118. 

Creosote poisoning, treatment of, 826. 

Cretinism, diagnosis of, 667; pathology of, 
667; symptoms of, 666, 667; three degrees 
of, 667; treatment of, 667; endemic, 666; 
epidemic and sporadic, 227, 664, 666. 



INDEX 



845 



Crises, cardiac, of ataxia, 703; Dietl's, 485; 
gastric, of ataxia, 70'2. 

Croup, 179; antitoxine and intubation 
combined in, 187; of measles, 181 ; pseudo, 
181; secondary, with stenosis, 181; true, 
181; with urgent stenosis, treatment of, 
181. 

Crowing sounds in the new-born, 93. 
Cryoscopy, 55, 56, 477. 
Cryptorchidism, 103, 495 
Crystals, Charcot-Leyden, in stools, 29. 
Culture, serum, for diphtheria, 581. 
Cultures, 40, 41. 

Cupping, dry, 80; wet, for relief of conges- 
tion and local hyperemia, 79. 

Cure, inunction, for syphilis, 499; milk, 235; 
mind, 278; rest, out of doors, 454, 455. 

Current, faradic, use of the, 683; galvanic, 
use of the, 683. 

Curschman's spirals, in asthma and bron- 
chitis, 36. 

Curvature of the spine, lateral, aetiology of, 
577; diagnosis of, 577; treatment of, 578. 

Cutis anserina, 796. 

Cyanosis in premature infants, 91. 

Cyclitis, plastic form of, 819; serous, 819; 
suppurative, 819. 

Cyclopia, 765. 

Cycloplegia, 813. 

Cylindroids, 25. 

Cyst, of the sweat glands, 790. 

Cystitis, causes of, 487; chronic, 487, 488; 
differential diagnosis of, and pyelitis, 487; 
symptoms of, 487; treatment of, 487. 

Cystoma, sebaceous, 790. 

Cystoscopy, 476. 

Cysts (in children), 99. 

Cysts, dermoid, 466; dermoid, of the liga- 
ment, treatment of, 528; dermoid, of the 
ovary, 528; treatment of, 528; hydatid, 
406, 466; non-malignant, 539; of the 
kidney, 491; of the liver (echinococcus), 
differential points and treatment of, 320; 
of the pancreas, 326, 327; ovarian, 405, 
406; paranephritic, 491; retention, 404; 
retention, of Bartholin, 523; serous, 405. 

Cytodiagnosis. 52. 

Cytolysis, 53, 54. 

Dactylitis, syphilitic, 539. 

Dandruff, 772. 

Deafness, 810; nervous, 809. 

Decapsulation of the kidney in Bright's 

disease, 472. 
Deciduoma malignum, 530. 
Decubitus, treatment of, 772, 773. 
Defecation, difficult, in infants, 129. 
Defects, congenital, 335, 336; valvular, 347. 
Defluvium capillorum, 772. 
Deformities, and malformations, common 

forms, 102-104; and malformations, rare 

forms, 104-107; of the nose, 423. 
Deformity, dental, family type of, 256. 
Degenerates, sexual, 506. 
Degeneration, chronic muscular, treatment 

of various forms of, 347; fatty, 96, 346; 

fatty, of muscle, 561. 



Degeneration, of the heart, muscular, 346; 
of the kidney, 478 ; of the nervous appara- 
tus of the intestine, 284; stigmata of, 106, 
767. 

Delirium, 715, 716; characteristics of, 681; 

treatment of, 716. 
Delirium cordis, 356. 

Dengue, etiology of, 630; diagnosis of, 631; 

treatment of, 631; symptoms of, 631. 
Depletion, local, for relief of congestion, 79. 
Derangements, functional in the male, 505- 

507; of the sexual function in the male, 

497. 

Dermatalgia, 795. 
Dermatitis, 773-775. 

Dermatitis ealorica, 773; prognosis and 
treatment of, 773. 

Dermatitis, diabetica, 774 ; gangrenosa 
adultorum, prognosis and treatment of, 
774; medicamentosa, 774; multiformis 
herpetiformis, 775; prognosis and treat- 
ment of, 775; traumatica, 775; venenata, 
prognosis and treatment of, 775. 

Dermatoneuroses, sensory, 795; trophic, 
796; vascular, 796. 

Deviation, conjugate, 812. 

Diabetes, aetiology, 651 ; causes of, exciting, 
652; causes of, predisposing, 651, 652; cir- 
culatory symptoms of, 654; constitutional 
symptoms of, 653 ; course and prognosis of, 
655; cutaneous complications of, 654; 
diagnosis of, 653; diet in, 656; external 
appearances of, 653; genitourinary symp- 
toms of, 654; mechanotherapy in, 657, 
658 ; mental symptoms of, 655 ; pathology 
of, 652, 653; specimen diet for one week 
for, 657; sugar in the urine of, 656; the 
blood in, 652; the brain in, 652; treatment 
of, 655; urine in, 653. 

Diabetes mellitus, acetone in the urine of, 
21; diacetic acid and /3-oxybutyric acid 
in the urine of, 22; sugar in the urine of, 
20; urine in, 19. 

Diabetic coma, 654, 655. 

Diagnosis, errors of, 419; gynecological, 
principles of (Edebohls), 508-516; labo- 
ratory aids to clinical, 17-56; technique 
of, 9. 

Diagnostic inquiry, 10. 
Diaphoretics, 74. 

Diarrhoea, 73; acute forms, dyspeptic, sim- 
ple, treatment of, 134, 135; acute, severe, 
cholera infantum, treatment of, 135, 136, 
137; amoebic, 141; and incontinence of 
faeces in adults, 286; choleraic, 476; 
chronic, in infants, 140; clinical forms of, 
286; in diphtheria, 177; in infants, 129; 
morning, 312; mucous, 287, 312; of ty- 
phoid fever, 624; secondary to other dis- 
eases, 287; summer, 134, 135; treatment of 
(in adults), 286. 

Diathesis, hemorrhagic, 145, 382. 

Diazo reaction in diagnosis of typhoid fever, 
24. 

Diet, 124, 236, 656; fever, 57, 58, 236; fluid, 
235; for children after weaning, 124; for 
children during second year of bottle feed- 



846 



INDEX 



ing, 124; for children after three years, 
124; for leanness, 239; for obesity, 239, 
659, G60; for obesity, specimen, 345; full, 
with certain restrictions, 236; in conva- 
lescent stage, 59; in diabetes, 656; in 
diphtheria, 179; in gout, 648; in scurvy, 
663; in tuberculosis, 454; light (soft) diet, 
235; milk, 58; of nursing mothers, 109; 
of variola, 639; substitute in indigestion 
and diarrhoea, 131; vegetable, 240. 

Dietetics, practical, 235. 

Dietl's crises, 485. 

Diets, special, 58. 

Digestion, artificial aids to, 265, 266; ex- 
ercise and, 240; organs of, 12. 

Digestive ferments, 265. 

Digestive system, the, 229, 332. 

Digestive tract, disorders of the, 124, 125. 

Digitalis, infusion of, in oedema, 388; in 
heart disease, 355. 

Dilatation, of the bowel, congenital and ac- 
quired, 288; of the colon, 287; of the stom- 
ach, diet in, 276; of the stomach, opera- 
tive treatment for, 277. 

Diluents of cow's milk, 116. 

Diphtheria, 171-179; and follicular tonsil- 
litis, difficulty of distinguishing clinically 
between, 172; antitoxine in, 175, 176; 
bacteriological diagnosis of, 172; diet in, 
179; fever in, 177; immunity, period of, 
for those exposed to, 174; incubation 
period, 171; isolation period, 604; larvata, 
173; local treatment of, 176; nasopharyn- 
geal toilet in, 81, 174; of the eye, 178; 
paralysis of the soft palate in, 179; rapid 
bacteriological diagnosis of, 41; stimula- 
tion in, 177; vomiting in, 177. 

Diplegia, 676. 

Diplococcus, mtracellulares, 743; lanceo- 
latus, 438. 

Disc, choked, 814, 820. 

Discharges, gonorrhceal, 521; vaginal, 521; 
vulvovaginal, 521. 

Disease, acute febrile, points to be remem- 
bered in the management of, 83, 84; Ad- 
dison's, 670; baker's, 687; Basedow's, 667; 
bronzed skin, 670; Buhl's, 96; caisson, 708; 
fish skin, 778; Friedreich's, 219; Glenard's, 
300; hemorrhagic, 96; hide-bound, 781; 
hip, 572, 580, 581, 582; Hodgkin's, 46, 380; 
hook worm, 299, 300; infectious, preven- 
tion of, in public schools, 605; infectious, 
prophylaxis for, 606; knee, 587; labyrin- 
thine, 809; Little's, 96, 261 ; mastoid, 809; 
Meniere's, 715; of the accessory sinuses 
of the nose, 424; of the base of the 
brain, 681; of the cerebral peduncles, 
681; of the external ear, fungous, 783; 
of the lacrymal apparatus, 817; of the 
pons, 681; of the thyreoid gland, 664, 
665; Paget's, of the nipple, 794; para- 
sitic skin, 782; Parkinson's, 693; Parry's, 
667; policemen's, 687; Pott's, 569; pros- 
tatic, 473; Raynaud's, 734, 796; Riga's, 
127, 247; Schoenlein's, 382; symptoms 
pointing to grave organic, 12; valvular 
heart, 347-355; venereal, in the female, 



505; venereal, in the male and female' 
497-500; Werlhoffs, 383; Winckel's, 92. 

Diseases, causes of, 10; requiring blood ex- 
amination, 45-50; of joints and bursa?, 
544; of the appendages, 797; of the ar- 
teries and veins, 359; of the chorioid, 819; 
of the ciliary body, 819; of the eyelids, 
816; of the gall bladder, 321 ; of the genito- 
urinary system, 469-532; of the kidneys, 
477; of the liver, 314; of the mouth, 242; 
of the new-born, 92-102; of the pancreas, 
324-329; of the peritonaeum, omentum, 
and mesenteric glands, 329 ; of the pitui- 
tary body, 672 ; of the oesophagus, 257 ; of 
the respiratory tract in children, 150, 
151, 152; of the sclera, 819. 

Disinfection, and prophylaxis, 603; of 
clothing, bedding, furniture, etc., after 
contagious diseases, 608; of sick room, 
190, 191, 607, 608. 

Dislocation of the hip, congenital, 583; 
a>tiology of, 583; Lorenz method of re- 
ducing, 584. 

Disorders, gastrointestinal, nomenclature of , 
125; menstrual, 516; of speech, 226; of the 
digestive tract, 124. 

Distention, gastric, 266; of the heart, 332. 

Distichiasis, treatment of, 817. 

Distoma haematobium, 492. 

Diuretics, and their doses, 78. 

Diuretin, 75; in oedema, 389. 

Diverticula, vesical, 486. 

Dose determination, rule for, 84. 

Douche bath, 66. 

Douching, vaginal, for vulvovaginalis of 
children, 209. 

Drainage, for ascites, 391, 392; in pleurisy 
with effusion, 463; of the abdomen, per- 
manent (Caille), 392, 393; of uterine cavi- 
ity in puerperal fever, .532; permanent, in 
ascites from cirrhosis of the liver, 393. 

Drop, hanging, 47. 

Dropsy, 387; cardiac, 388; encysted, 404; 
essential, 403; general management of, 
388; idiopathic, 403; of bursa>, 406; of 
joints, 406; of tendons, 406; of the am- 
nion, 406; of .the gall bladder, 404, 405; 
toxic, 403; treatment of, with drugs, 389; 
venesection in, 389; without albuminuria, 
403. 

Drug eruptions, 774, 775. 

Drug habits and treatment, 830. 

Drug stimulation, 71. 

Duboisia poisoning, treatment of, 827. 

Duodenum, congenital hypertrophic stenosis 

of the pylorus and, 104. 
Dysacusis, 810. 
Dyssesthesia, 795. 

Dysentery, 139; clinical varieties of, 290, 
treatment of, 290, 291. 

Dysmenorrhcca, 517; treatment of, 517. 

Dyspepsia, acute, 273, 274; acute, symp- 
toms and treatment of, 273; amylaceous 
fermentative, 301; chronic, 274, 275; 
chronic, clinical varieties of, 274, 275; 
nervous, 265, 277; nervous, diagnosis, 
prognosis, and treatment of, 277; of preg- 



INDEX 



847 



nancy, 278; with dilatation and atony of 
the stomach, 276; with hyperchlorhydria, 
278, 279. 

Dyspnoea, 77; cardiac, prescription for, 
354, 355. 

Dystrophies, muscular, 565. 

Dystrophy, muscular, 678, 679; muscular, 
progressive, a-tiology of, 565; muscular, 
progressive, diagnosis of, 566; muscular, 
progressive, pathology of, 566; muscular, 
progressive, symptoms of, 565; mus- 
cular progressive, varieties of, 566. 

Dysuria, 475. 

Ear, ailments, minor or local, 807; diseases 
of the, treatment of, 810; foreign bodies 
in the, 808; injuries, formulary for, 811; 
middle, chronic purulent inflammation of 
the, 809 ; polyps of, 809 ; treatment of, 808. 

Earache, 806; acute, treatment for, 811. 

Ebstein, Banting and, systems of diet, 239. 

Echinococcus, 320; cyst, 328; taenia, 30; 
treatment of. 492. 

Echokinesis, 691. 

Echolalia, 691. 

Eclampsia, 716, 717, 720; puerperal, 716, 
717; puerperal, diagnosis of, 720; puer- 
peral, prognosis of, 720; puerperal, proph- 
ylactic treatment of, 720; puerperal, 
symptoms of, 717; puerperal, temperature 
in, 717; puerperal, treatment of, 720. 

Ecthyma, 776. 

Eczema, 776, 808; acute, 777; chronic, 
treatment of, 777; erythematosum, 776; 
fissum, 776; of the lips, 250; of the um- 
bilicus, 95; papulosum, 776; pustulosum, 
776; rubrum, 776; sclerosum, 776; squa- 
mosum, 776; verrucosum, 776; vesiculo- 
sum, 776. 

Effusion, articular, 53; pericardial, indica- 
tions and method of tapping for, 396; 
peritoneal, 52; pleuritic, 393; pleuritic, 
signs of, 393. 

Ehrlich's myelocytes, 369; side chain hy- 
pothesis, 53. 

Electricity, 681, 682, 683; action of, on living 
tissue, 682; forms of, used in medicine, 
682 ; in practice, 682, 683 ; remarks on the 
application of, 681; static use of, 683. 

Electrolysis, 682. 

Electrotonus, 682. 

Elephantiasis arabum, 785. 

Emansio mesium, 516. 

Embolism, cerebral, 696. 

Emmetropia, 821. 

Emphysema, 444, 445, 458; atrophic, 445; 
compensatory, 444; idiopathic, 444; in- 
terstitial, 444; of the lung, 444, 445; of 
the lung, causes of, 444; of the lung, 
general characteristics of patient suffer- 
ing from, 444; of the lung, treatment of, 
445; of the mediastinum, 468. 

Empyema, 161, 166, 462 ; chronic (in 
children), treatment of, 166; fever in, 167; 
termination of, 165. 

Encephalitis, suppurative, 761, 762. 

Encephalocele, 98, 99. . 



Endarteritis, 644, 735, 749; obliterans, 735; 

of gouty origin, 644; syphilitic, prognosis 

of, 749; syphilitic, symptoms of, 749; 

syphilitic, treatment of, 749. 
Endocarditis, acute, 339 ; acute, diagnosis of, 

340; acute, treatment of, 340; chronic, 341 ; 

in rheumatism, articular, 548; ulcerative, 

612. 

Endometritis, 521; acute, treatment of, 
522; chronic, physical examination of, 
522; chronic, symptoms of, 522; chronic, 
treatment of, 522. 

Enemata, high, 63; low, 64. 

Entamoeba coli, 300; dysenterise, 300. 

Enteralgia, 282. 

Enteritis, 287, 288, 289; acute catarrhal, 
288; clinical varieties of, 289; chronic, 
differential points of, 290; follicular, 139; 
membranous, 139, 287. 

Enteroclysis, 63, 69, 284; in Bright 's dis- 
ease, 479; in collapse of asiatic cholera, 
634; in intestinal indigestion, 303; method 
of performing, 71. 

Enterocolitis, 139, 330. 

Enteroptosis, 300; clinical features of, 300, 
301; treatment of, 301. 

Enterospasm, 269. 

Entropion, treatment of, 817. 

Enuresis, 213; clinical varieties of, 213; 
treatment of, 213. 

Eosinophile cells in sputum of tuberculosis, 
450. 

Eosinophilia, 372. 

Epididymitis, 495; treatment of, 495. 

Epiglottis, sarcoma of the, 422. 

Epilepsy, aetiology of, 721; aurse of, 722; 
clonic stage of, 722; coma stage of, 722; 
convulsions, three stages of, in, 722; 
cortical, 721; diagnosis of, 723; Gower's 
table for distinguishing hysteria from, 723 ; 
idiopathic, 721; Jackso'nian, 721,. 723; 
Jacksonian, from tumor of the brain, 
758; nocturnal, 723; partial, 721; post- 
epileptic symptoms of, 722; procursive, 
722; prognosis of, 724; psychical, 721, 
723; spasm, tonic of, 722; symptomatic, 
721; symptoms of, 722; treatment of, 724. 

Epiphora, 817. 

Epiphysitis, acute, symptoms of, 536; acute, 

treatment of, 536. 
Epispadias, 103. 
Epistaxis, 423. 

Epithelioma, 793; discoid, 793; nodular, 
793; of the larynx, 421; papillary, 793; 
superficiale, 793; treatment of, 793. 

Epithelium, 26. 

Erb's symptom, 212. 

Erethism, sexual, 505. 

Ergot, aseptic, pulmonary in oedema, 401. 

Ergotism, treatment of, 828. 

Erosions in the nose, 418; of the stomach, 
279. 

Eruptions, drug, 774, 775; treatment of, 
775. 

Eruptive and other fevers, 198, 199. 
Erysipelas, 785; ambulans, 785; phlegmo- 
nous, 785; rose, 785. 



848 



INDEX 



Erythema, 777; acrodynic, 796; chronic 
trophoneurotic, 796; in infants, 94; in- 
tertrigo, 777; multiforme, 777; nodosum, 
777; simplex, 777. 

Erythrocytes, 368. 

Erythromelalgia, 735, 796. 

Ether, as an anaesthetic, 823. 

Euquinine in malaria, 615. 

Ewald and Boas test breakfast, 32, 268. 

Ewald's test, 268. 

Examination, of patients for nervous de- 
rangements, 684; of the blood for Plas- 
modium malaria?, 15; of the pelvic or- 
gans in females, 510, 511, 512; recognition 
and grouping of symptoms during, 11, 12; 
regional, 14, 15; scheme of, in nervous 
derangements, 683; special, 16. 

Examinations, chemical, of the stomach 
contents, 32-35; clinical, of the stomach 
contents, 31, 32; general, of patients, 10, 
11, 12; gynaecological, 512, 513; micro- 
scopic, of sputum, 36, 37; microscopic, of 
stomach contents, 32; special, incision 
and exploratory puncture in, 16; special, 
Rontgen rays in, 16. 

Excoriations and erythema, 94. 

Exercise and digestion, 240. 

Exophthalmus, 814. 

Exostoses, 539. 

Expectorants and cough mixtures, 75; 

in bronchitis, 444. 
Expression, facial, 11. 
Exstrophy of the bladder, 486. 
Exudates, 38, 39, 407; inflammatory, 395; 

seropurulent, 396. 
Exudations, syphilitic, into the meninges, 

749, 750. 

Eye, formulary, 822; gouty affections of the, 
647; injuries of the, 815; laceration of the, 
815; perforating injury of the, 815; pupils 
of the. 814, 815. 

Eyelids, diseases of the, 816; puffy, 817. 

Eyes, care of, in the new-born, 88. 

Eye sight, 821. 

Eye strain, 821 ; treatment of, 822. 

Facts about milk, 113. 

Faeces, bacilli in, 29, 30; bacteria, bile, 
crystals, fat, fibrin, and parasites in the, 
271; characteristics of, 27; disinfection of, 
in typhoid fever, 618; examination of, 
27-30, 270, 271; foreign bodies in, 27; 
impaction of, 305; incontinence of, 287; 
incontinence of, plastic operation for, 287; 
in vomit, 32; microscopical examination 
of, 28; protozoa in, 29. 

Far-sightedness, 821. 

Farcy, 785. 

Fasciae, contractures of, 568; palmar, con- 
traction of, 568. 
Fat in stools, 28. 
Fats, 231. 

Fatty heart, 345; degeneration (Buhl's 

disease), 96. 
Feeding by the rectum, 59; by the stomach, 

60; cases, difficult, in bottle-fed infants, 

132; forced, see Gavage. 



Feeding, infant, 107-110; infant, cow's milk 
for, 119; infant, mixed, 112; infant, sum- 
mary of, 110, 111; in infectious fevers, 59; 
in sickness, 57-60; subcutaneous, 59; 
subcutaneous, formula for, 59; summary 
of, with cow's milk, 122; table, for healthy 
infant the first year, 123. 

Fermentation, intestinal, 301, 302; putrid 
proteid, 301. 

Ferments, digestive, 265. 

Fever, 13, 64, 236, 604, 744, 745; anti- 
pyretic measures in, 64; blisters, 777; 
cerebrospinal, 743, 744, 745; chills in, 13; 
clinical varieties of, 622; contagious, 
management of, in private houses, 604: 
diet for adults and older children, 236; 
diet in, 57, 58; enteric, 616, 617; enteric, 
diagnosis of, 621; enteric, differential 
diagnosis of, 621, 622; enteric, of con- 
valescence, 619-621; enteric prevention 
of the spread of, 617; enteric, prognosis 
of, 623; enteric, symptoms of, 619; gland- 
ular, 206; hay, 427; in diphtheria, 177; 
infectious and contagious, 602; in pyo- 
thorax, 152; intermittent malarial, prog- 
nosis of, 614; isolation period of, 604; 
malarial, 207, 318, 609; malarial, com- 
plications, 614; malignant purpuric, 743, 
744, 745; of gout, 647; petechial, 743, 
744, 745; pollen, 427; puerperal, treat- 
ment of, 531, 532; relapsing, definition 
of, 631; relapsing, diagnosis of, 632; re- 
lapsing, prognosis of, 632 ; relapsing, 
serum therapy in, 632; relapsing, symp- 
toms of, 631 ; relapsing, treatment of, 632; 
rheumatic, 547 ; scarlet, 201-206 ; sig- 
nificance of, and pain, 13, 14; spotted 
(cerebrospinal meningitis), 743, 744, 745; 
typhoid, diazo reaction test in, 24; typhus, 
628-630; yellow, 627. 

Fevers, eruptive and other, 198, 199; in- 
spirations of cold air in, 69; intermittent, 
609; intermittent, latency and relapse in, 
614; malarial, aetiology of, 609; malarial, 
geographical distribution of, 609 ; malarial, 
parasitology of, 609. 

Fibres, elastic, in sputum, 36. 

Fibroma molluscum, 790; of the vocal cord, 
420; simple, 790. 

Fibromata, 528; of bone, 540. 

Filaria sanguinis, 492; sanguinia hominis, 
examining blood for, 48. 

Fingers, dead, 734; web, 104. 

Fish poisoning, treatment of, 827. 

Fission fungi, 784. 

Fissure of the rectum, 309. 

Fissures, congenital, gaps and, 106; of the 
lips, 250. 

Fistula, branchial (in infants), 105; con- 
genital, 257; gastric, for feeding in stric- 
ture above the stomach, 283; in ano, 306; 
retro vaginal and vaginovesical, 525; um- 
bilical, 106. 

Flat foot, acquired, traumatic form, 592; 
of children, 595 ; rhachitic, 142, 592 ; 
static, 593; symptoms of, 593; treatment 
of, 594. 



INDEX 



849 



Fleiner's test meal, 268. 
Flies, poisoning by, 828. 
Fluid, cerebrospinal, 53, 407; diet, 235; in 

the chest, physical diagnosis of, 161. 
Fluids, chylous, 407. 

Flushing, of the colon, 63; of the stomach 
and bowels, 60, 61. 

Food, absorption of, 230; component parts 
of, 231; digestibility of, 230; pancreatized, 
238; predigested, 238; values, 232. 

Foods, concentrated, 238. 

Foot, club, 104; treatment of, 581. 

Foot, club, paralytic, 592; symptoms of, 590. 

Foot, flat. See Flat Foot. 

Foot, madura, 783. 

Foreign bodies in the ear, 808; removal of, 
808. 

Foreskin, oedema of, 402, 403; oedema of, 
treatment of, 402. 

Formalin vapor as a disinfectant, 191, 607. 

Formula^, office, for nose and throat treat- 
ment, 429, 430. 

Formulary, eye, 822; for ear injuries, 811; 
in skin diseases, 798-805; otic, 811. 

Fowler's solution, treatment of poisoning 
by, 826. 

Fracture, of the neck of the femur, 586; 
sprain, 545. 

Fractures, in infants, 107; of bones, 542. 

Frambcesia, 789. 

Freckle, anti-lotion, 804. 

Freckles, 772, 804. 

Fremitus, vocal, 163. 

Frenum, ulcer of the, 247. 

Friction, of the abdomen, 597; thigh, in chil- 
dren, 506. 

Friedlander's pneumobacillus, 438. 

Friedreich's disease, 219, 704. 

Fuller's alkaline treatment of rheumatism, 
550. 

Fungus haematodes, 757. 
Furunculus, 785, 808. 

Gag, Denhard's, 183. 

Gait, 533; ataxic, 703; steppage, in palsy, 
713. 

Gall bladder, dropsy of the, 404. 
Gallstone colic, 322; crepitus (in dropsy), 
404. 

Gallstones, 321, 322, 323, 324; expulsion of, 
323; mortality after operations for, 324; 
treatment of, 323. 

Ganglia, 568. 

Ganglion, compound and simple, 406, 568. 

Gangrene, local, 735, 796; of the lung, 36, 
161; of the lung, diagnosis of, 433; of the 
lung, prognosis of, 433 ; of the lung, symp- 
toms of, 433; of the lung, treatment of, 
433; symmetrical, 796. 

Gas poisoning, treatment of, 827. 

Gastralgia, 282; neurotic form of, 283. 

Gastricismus, 273; treatment of, 273. 

Gastritis, acute, 273, 274; acute catarrhal 
(of infants), 131, 132; atrophic, 275; in- 
fectious, 274; parasitic, 274; phlegmonous, 
274; simple chronic, 275; toxic, 274. 

Gastroenteritis, acute, 73, 138, 289. 



Gastroenterostomy in "inoperable" stricture 
of the lower stomach and duodenum, 283. 
Gastrointestinal ailments in adults, 273. 
Gastroplication, 283. 

Gastrotomy, 283; for direct inspection, 283; 
for feeding in stricture above the stomach, 
283. 

Gavage, 60, 186, 223 ; in cerebrospinal men- 
ingitis, 223; indications for, 60. 

Genital organs, male, localized and minor 
ailments of the, 492, 493. 

Genitourinary system, the, 469-532. 

Genu valgum, 146. 

Genu varum, 147. 

Gestation, ectopic, 525. 

Gigantoblasts, 368, 374. 

Gingivitis, 243. 

Gland, enlarged thymus, in infants, 101; 
suprarenal, 670; thymus, abscess of, 170; 
thymus, atrophy of the, 142; thymus, en- 
larged, 468 ; thyreoid, disease of the, 664. 

Glanders, 785. 

Glands, Bartholin's, inflammation of, 523; 
diseases of the mesenteric, 329; ductless, 
derangements of the, 664; sebaceous, dis- 
eases of the, 771 ; Skene's, inflammation of, 
522; Skene's, inflammation of, treatment 
of, 523; sweat, diseases of, 770; tuber- 
culous, 365; vulvovaginal, inflammation 
and abscess of the, 522. 

Glaucoma, 819, 820; acute form of, 820. 

Gleet, 504. 

Glenard's disease, 301. 

Gliomata, 757. 

Globus hystericus, 728. 

Glossitis, diffuse, 247. 

Glottis, oedema of the, 402, 426. 

Glycosuria, alimentary, 651; and diabetes 
mellitus, 651. 

Goitre, and tumor, malignant, of the thy- 
reoid, 670; varieties of, 670. 

Goitre, exophthalmic, aetiology of, 667; ex- 
ophthalmic, nervous symptoms in, 668; 
exophthalmic, symptoms of, 668; exoph- 
thalmic, treatment of, 669, 670; exoph- 
thalmic, trembling in, 668; "pulsating," 
670. 

Gonagra, 643. 

" Goneness," 356. 

Gonococcus, 42; Gram's method of staining 
gonococci, 38, 39; in genitourinary dis- 
charges, 38; in urine, 26. 

Gonorrhoea, 497, 502; abortive treatment 
of, 503; course and symptoms of, 502; in 
children, 208; prophylaxis of, 502; treat- 
ment of, 503. 

"Gonorrhoea! shreds," 38. 

Goose skin, 796. 

Gout, 549; acute, 645, 647; aetiology of, 
644; affecting the circulatory system, 
646; and rheumatism, clinical differences 
between, 647; causes of, extrinsic, 644; 
causes of, intrinsic, 644; chronic, 646, 647; 
definition of, 643; diet in, 648; differential 
diagnosis of, 647; fever of, 647; local 
treatment of, 650; pain in, relief of, 649; 
prognosis of, 648; retrocedent, 647; 



850 



INDEX 



rheumatic, 647; symptoms of, 645; 

synovial fluid in, 643; treatment of, 648, 

649; visceral or irregular, 646. 
Gower's table for distinguishing epilepsy 

from hysteria, 723, 724. 
Grain poisoning, treatment of, 828. 
Gramme values, practical approximate, 86. 
Gram's method of staining gonococci, 38, 

39. 

Grand mal, 721, 722, 758; from tumor of 

the brain, 758. 
" Granular lids," 817. 
Granulations, 189, 809. 
Granuloma, fungoides, 794; removal of, 95. 
Graves's disease, 667. 
" Green sickness," 373. 
Growth, stunted, 99. 

Growths, adenoid, 194, 195; benign, 789- 
793 ; benign and new, of the female pelvis, 
527; benign and malignant, 491, 492; 
malignant, 420, 421, 491, 492; malignant 
new 529; new, 789; new, in the nose, 420; 
parasitic, of the brain, 762; tuberculous, 
757. 

Gruels, dextrinized, 117. 
Grutum, 771. 

Gummata of the brain, 750 ; of the meninges, 
757; syphilitic, 538. 

Gums, bleeding, 243, 245; bleeding, in in- 
fants, 126; discoloration of the, 243; 
spongy, 243. 

Giinzberg's test, 31. 

Habit chorea, 691. 
Habit spasm, 691. 

Haematidrosis, prognosis and treatment of, 
770, 771. 

Hematocele, treatment of. 496. 525. 

Haematoidin in sputum, 36. 

Hematoma, of the dura mater, 747; of the 
sternocleidomastoid, 98; pelvic, 525. 

Hsematopathology, 368. 

Haematoporphyrin in urine, 24. 

Haematoporphyrinuria, in phthisis, ex- 
ophthalmic goitre, typhoid fever, and 
hydroa aestivalis, 24. 

Hematuria, 472; causative factors of, 472. 

Haemidrosis, 734. 

Haemoglobin in the urine, 22. 

Haemoglobinsemia, 370. 

Haemoglobinometer, 42. 

Hemoglobinuria, 472; paroxysmal form of, 
473. 

Haemolysis, 53, 54. 
Haemopericardium, 342. 
Haemophilia, 370, 384; treatment of, 384, 
385. 

Haemoptysis, 433. 

Haemorrhage, between the dura mater and 
the pia mater, aetiology, prognosis and 
symptoms of, 752, 753; between the dura 
mater and the skull, aetiology, symptoms 
and treatment of, 752; cerebral, etiology, 
695; diagnosis of, 696; pathology of, 695; 
symptoms of, 695; concealed, 385; extra- 
medullary, 763; from sloughing of the 
tissues in diphtheria, 178; from the in- 



testines, treatment of, 297 ; from the lungs, 
433; from the lungs, source of, 433; from 
the lungs, symptoms of, 433; from the 
lungs, treatment of, 433; from the nose, 
423; from the stomach, 281, 282; from the 
stomach, in anaemia, 674; gastrointestinal, 
96 ; into the pancreas, 325 ; into the spinal 
membranes, 763; into the spinal mem- 
branes, aetiology of, 763 ; into the spinal 
membranes, diagnosis of, 764; into the 
spinal membranes, pathology of, 763; 
into the spinal membranes, prognosis of, 
764; into the spinal membranes, symp- 
toms and treatment of, 764; into the vit- 
reous, 816; intracranial, 385, 695; menin- 
geal, 752; remarks on external, visible and 
invisible, 385; saline infusion in, 70; sub- 
periosteal, 534; umbilical, 96; visible, 385. 

Haemorrhages, 93, 96, 281, 325, 674; ocular, 
in the new-born, 93. 

Haemorrhoids, 307-309; internal, 307; treat- 
ment (operative), 30S; treatment (pallia- 
tive), 307. 

Haemothorax, 464, 465. 

Hair, atrophy of the, 797; treatment of, 797; 
hypertrophy of the, 797. 

"Hanging drop," 47. 

Hare lip (in infants), 102. 

Hay fever, 427; pollantin in, 428; treat- 
ment of, 428. 

Headache, 15, 302, 688, 689, 757; aetiology 
of, 689; a symptom of multiple origin, 15; 
bilious, 690; diagnosis of, 689; differential 
points of, 689; from tumor of the brain, 
757; neurasthenic, 689; nodular, 689; sick, 
attacks of, 302, 689 ; suggested, 689; treat- 
ment of, 689; various forms of, 688. 

Head injuries, diagnostic value of fluid dis- 
charges from the ear in, 811. 

Head nodding, 691; and nystagmus in 
rhachitic children, 210. 

Hearing, impairment of, 810; painful, 810; 
testing the, 806. 

Heart, arrhythmia of the, 357; chronic de- 
generation of the, not due to valvular 
defects, 346; congenital malformation of, 
100, 351 ; congenitally small, 344; degener- 
ation of the, 346; dilatation of the, 337, 
338 ; dilatation of the, physical signs of the, 
338; fatty, 345; fatty, thyreoid treatment 
in, 345; fatty, two classes of, 345; fibroid, 
346; gouty, 346; hypertrophy of the, 336; 
muscular degeneration of the, 346, 347; 
neurasthenic, 356; neurasthenic, weakness 
of, 344 ; neuroses of the, 356 ; palpitation of, 
in gout, 646; paroxysmal, rapid, 358; 
position of the, 333; runaway, 646; rup- 
ture of the, 339; senile, 346; size of the, 
333; slow, 358; syphilitic, 346, 347; weak, 
335, 344; weak, influence of a, on the cir- 
culation, 335; weakness of the, in Addi- 
son's disease, 671 ; weight of the, in hyper- 
trophy of the. 336. 

Heart disease, digitalis treatment in, 355; 
valvular, 347-355; valvular, principles 
and treatment of, 351, 352; visceral 
neuralgias simulating other disease in, 355. 



INDEX 



851 



Heart failure, 337. 

Heart lesions, 335 ; baths, medicated, in, 353; 

normal temperature in, 15; valvular, 

348-355. 
Heart murmurs, 334. 
Heart muscle, flabbv, 344. 
Heart strain, 338, 339. 
"Heart thumping," 278. 
Heat, and nitric acid test for albumin, 19. 
Heat, units of, required in food per day, 

232. 

Heat values, 232. 
Heberden's nodes, 552, 553. 
Hebra's water bed, 67. 
Hegar's sign, 515. 

Hemianesthesia in cerebral apoplexy, 695. 

Hemianopsia, 812; from tumor of the brain, 
758, 759; in cerebral apoplexy, 695. 

Hemiatrophy, facial, 736; facial, prognosis 
of, 737; facial, symptoms of, 737. 

Hemicrania, 689; aetiology of, 689; pain of, 
690; pathology of, 690; prognosis of, 690; 
symptoms of, 690; treatment of, 690. 

Hemiplegia, 676; in cerebral apoplexy, 
695; spasmodic infantile, 217. 

Hemlock poisoning, treatment of, 827. 

Hepatization, caseous, 439. 

Hermaphroditism, 493. 

Hernia, clinical varieties of, 298; inguinal, 
97; of the ovary, 524; operation for, in 
children, 97; strangulated, 297; strangu- 
lated, symptoms and treatment of, 298; 
umbilical, 97. 

Herpes, 249, 493, 686, 777; facialis, 777; 
labialis, 777 ; of the lips, 249 ; of the tongue, 
249; prseputialis, 493; progenitalis, 777; 
simplex, 777. 

Herpes zoster, 686; ophthalmicus, 777; 
prognosis and treatment, 777. 

Hiccough, 269; obstinate, 694. 

Hip disease, 572, 581 ; diagnosis of, 580, 581 ; 
fixation treatment in, 573; malposition of 
the limb in, 580; treatment of, 581, 582. 

Hip dislocation, 584, 586; aetiology of, 583; 
congenital, age at which to operate for, 
586; congenital, bloodless reduction of, 
584 ; congenital, bloody method of re- 
ducing, 586; congenital, Lorenz method 
of reducing, 584; congenital, symptoms 
of, 584; treatment of, 584. 

Hippus, 815. 

Hirsuties, 797. 

Hook worm disease, 299, 300. 

Hordeolum, treatment of, 816. 

Hot air treatment, 600; of rheumatism, 551. 

Hunger, air, 372. 

Hyaline casts, 24. 

Hydatid cysts, 406. 

Hydatid thrill, 406. 

Hydramnios, 406. 

Hydrencephaloid, 398. 

Hydroa herpetiformis, 775. 

Hydrocarbons, 231. 

Hydrocele, congenital, 100, 405; definition 
and differential diagnosis, 405; injection 
and tapping in, 405; of the cord, 405; 
treatment of, 405, 496; vaginal, 496. 



Hydrocephalus, acquired internal chronic, 
225; acute, 225; chronic, 398; chronic ex- 
ternal, 226; congenital internal, 224; 
spurious acute, 398. 

Hydrocephalus, 224-226, 397, 398; symp- 
toms and treatment of, 225, 398 ; tapping 
cranium and spine in, 398. 

Hydrochloric acid, HC1, 264, 265; in stomach 
contents, 31. 

Hydrocyanic acid poisoning, treatment of, 
826. 

Hydrocystoma, 790. 

Hydronephrosis, 328, 404; prognosis and 

symptoms of, 404. 
I Hydropericardium, 342. 
Hydrophobia, aetiology of, 832; differential 

points of, 832; paralytic stage of, 832; 

pathology of, 832; symptoms of, 832; 

treatment of, 832. 
Hydropneumothorax, 465. 
Hydrosalpinx, 405. 
Hydrotherapy, 65. 

Hydro thorax, 464; non-inflammatory, 395; 

signs of, 393. 
Hygroma, congenital, 99. 
Hyperacidity, 264. 
Hyperacusis, 810. 

Hyperemia, 316; local, depletion of, by 
means of scarification, wet-cupping, and 
leeching, 79; of the kidneys, 477. 

Hvpersesthesia, 428, 679, 795; auditory, 810; 
ocular, 812; retinal, 812. 

Hyperchlorhydria, dyspepsia with, 278. 

Hyperidrosis, 734; of tuberculosis, 457; 
prognosis and treatment of, 771. 

Hyperinosis, 369. 

Hyperleucocytosis of pneumonia, 371. 
Hypermetropia, 821. 
Hyperpyrexia, 205. 
Hypertrichosis, 797. 

Hypertrophy, cardiac, 336, 337; of bone, 

541; of muscle. 562; of the bladder, 486; 

of the hair, 797; of the lingual tonsil, 426; 

of the tonsils, 425; weight of the heart in, 

336. 
Hypinosis, 369. 

Hypnotism, 732; clinical symptoms of, 732; 
in asthma, 460; method of inducing, 
733. 

Hypochondriacs, 726. 

Hypodermoclysis, 71; apparatus for, 72. 

Hypoleucocytosis of pneumonia, 371. 

Hypospadias, 103, 492, 493. 

Hypothesis, side chain, 53. 

Hypothyroidism, 666. 

Hysteria, 728 ; astiology of, 228 ; diagnosis of, 
728; in children, 226-228; mental symp- 
toms of, 729 ; paralyses of, 728 ; pathology 
of, 728; prognosis of, 729; symptoms of, 
728, 729; traumatic, 730; treatment of, 
729; urine in, 729. 

Hysteroepilepsy, 728. 

Ice bag for pain of pneumonia, 441. 
Ice cap, 68. 

Ice cream poisoning, treatment of, 827. 
Ice poultice, 68. 



852 



INDEX 



Ichthyosis, 778; congenital (grave form), 94; 
hystrix, 778 ; prognosis and treatment of, 
779; sebacea, 94; simplex, 778. 

Icterus gravis, 315. 

Idiocy, 228; amaurotic family, 228; amau- 
rotic family, pathology and symptoms of, 
768. 

Ideas, imperative, 210. 
Ileocolitis, protracted, 140. 
Imbecility, 228. 

Immunity, 53; active, 54; passive, 54. 

Impaction, faecal, 283, 285, 305, 306; diag- 
nosis and treatment of, 305, 306. 

Impetigo, contagiosa, 778; simplex, 778. 

Impotence, functional, 507; of the male, 
506, 507. 

Impressions, maternal, 106. 

Incision, and exploratory puncture in special 
examinations, 16; linear, for cedema, 390. 

Incompetence, aortic, 348; functional mi- 
tral, 349. 

Incontinence, 213, 287, 475, 519; of faeces, 
plastic operation for relief of, 287; of 
urine, 213, 475; of urine, in the adult 
female, 519. 

Indican in the urine, test for, 22. 

Indigestion, acute (of children), 131, 132; 
chronic, in children, 133, 134, 274; pro- 
longed (of infants), 132. 

Indoxyl, test for, in the urine, 302. 

Indurata, 771. 

Infant bathing, 89. 

Infant feeding, 107-110, 123. 

Infant mortality, 107. 

Infants, breasts of, 94 ; difficult feeding 
cases in bottle-fed, 132; hygienic manage- 
ment of, 121; nursing, no drugs for, 112; 
premature, cyanosis in, 91; premature, in- 
cubator for, 91; premature, treatment of, 
90; rhachitic, 129; stomach capacity of 
breast fed, 108. 

Infarction, haemorrhagic, in the lung, 432; 
pulmonary, 432; septic, 432. 

Infection, 533, 602, 603; of the genitourinary 
tract, 469; of the pelvic organs, 526; 
puerperal, 531. 

Infiltrations, tuberculous, 419. 

Inflammations, acute, of the oesophagus, 
258; chronic, of the oesophagus, 258; fol- 
licular, 305; skin, 773. 

Inflation, colon, 64; of the lower gut, 270. 

Influenza, 625; definition of, 625; differen- 
tial diagnosis of, 626; febrile type of, 626; 
nervous type of, 626; of children, 626; 
of children, treatment of, 626; symptoms 
and clinical varieties of, 625; treatment 
of, 626. 

Infusion, apparatus for, 72, 73; venous, 73. 

Inhalations, 77. 

Inhalation therapy, 77. 

Injuries, cerebral, direct, 676; of the spinal 

cord, 763; to the brain. 751, 752. 
Inoculation, 640; symptoms of, 640. 
Insanities, characteristics, 681. 
Insomnia, 78, 681, 731, 732; due to cerebral 

anaemia, 732; in the absence of pain, 78; 

mental suggestion for, 732; of tubercu- 



losis, 457; prescription for, 355, 361; 
treatment of, 731; with dyspnoea, 361. 

Insufficiency, heart, 335; heart, treatment of, 
353; kidney, 471 ; renal, 55, 476; renal, and 
newer aids to diagnosis, 476; renal, test 
for, 476. 

Intellection, disorders of, 681. 

Intestine, atony of the, 269; benign and 
malignant neoplasms of the, 295; clinical 
pathology of the, 268, 269 ; degeneration of 
the nervous apparatus of the, 284; haemor- 
rhage from the, 297; treatment of haemor- 
rhage from the, 297 ; obstruction, acute and 
chronic, of the, 296; paresis of the, 284; 
perforation of the, in typhoid fever, 625; 
tuberculosis of the, 292. 

Intoxicants, 825. 

Intoxication, acute, treatment of, 831; 
septic. See Septicaemia. 

Intubation, and tracheotomy, 183; how to 
operate for, 184; how to remove the tube 
in, 186; in croup, 183; in diphtheria, points 
to be regarded in, 185; in the adult, 187; 
in whooping cough, 169; nasal, in retro- 
pharyngeal abscess, 198; size of tube in, 
185; statistics of Budapest-Stephanie 
Children's Hospital, 187; stenosis after, 
187; tubes, retained, 186 technique of, 
185. 

Intussusception, 97; of the intestine, 296. 

Inunction treatment for syphilis, 499, 501. 

Invagination of the intestine, 296. 

Inversion, in cedema, subacute pulmonary 
form, 401; of the bladder, 486; of the 
uterus, 514. 

Iodine poisoning, treatment of, 826. 

Iodophilia, 48, 49, 50; its relation to pneu- 
monia, 49. 

Iridoplegia, 812. 

Iritis, 819; syphilitic, 819; treatment of, 
819. 

Irrigation, of the stomach, 62; of the uterine 

cavity in puerperal fever, 532. 
Isolation in fevers, 604. 
Itch, treatment of, 782. 
Ivy poisoning, 827. 

Jaundice, 92, 314, 315, 316; as a symptom 
of disease of the liver, 314; associated 
with symptoms, 314; catarrhal, in children 
and adults, 315; clinical forms of, 315; 
hepatic, 315; infectious, 92, 315; in the 
new-born, 92; malignant, 316; mild 
catarrhal, 315; obstructive, 315; prognosis 
of, 315; toxaemic, 315; with reference to 
its origin, 315. 

Johimbin (subcutaneously) for functional 
impotence, 507. 

Joint, hysterical, 588. 

Joint lesions, clinical varieties of, 545. 

Joints, 406, 544, 547, 550, 558; abscess of, 
546 ; abscess of, symptoms of, 547 ; diseases 
of, symptoms of, 544; diseases of, treat- 
ment of, 544; dropsy of, 406; hysterical, 
550, 588; loose bodies in, 558; loose bodies 
in, x ray print to demonstrate, 558; 
neoplasms of, 559; neuroses of, 559; 



INDEX 



853 



neuralgic conditions in neuroses of, 559; 
treatment of neuroses of, 559; pain in, 
and muscles, 15; rheumatism of the, 551; 
stiff, treatment of, by massage and move- 
ments, 598; swollen, in scarlet fever, 205; 
tuberculosis of the, diagnosis of, 557; 
tuberculosis of the, exciting cause of, 
557; tuberculosis of the, prognosis of, 558; 
tuberculosis of the, symptoms of, 557; 
tuberculosis of the, treatment of, Bier's, 
558. 

Juice, gastric, 263. 

"Jumping Jack" symptom of tetany, 212. 

Kakke, 713. 
Kalodol, 59. 
Keloid, 791. 

Keratitis, interstitial, 818; parenchymatous, 

818; phlyctenular, 818, 819. 
Keratosis, 776. 

Kernig's sign in meningitis, 222, 738. 

Kidney, 295, 471, 478, 480; abnormal 
position of the, 484; cirrhosis of the, 480; 
congestion of the, treatment of, 477, 478; 
cysts of the, 491; degeneration of the, 
125, 478; epithelium, 472; floating, 484; 
gouty, 644, 646 ; insufficiency of the, sys- 
temic poisoning from, 471; lesions, sum- 
mary of diagnostic points in, 485; mov- 
able, 295, 484; movable, and appendicitis, 
484; movable, and Bright's disease, 484; 
movable, straight front corset as a sup- 
port to abdomen for, 484, 485; movable, 
symptoms of, 484; movable, treatment of, 
484; rupture of the, 477; rupture of the, 
subcutaneous, 478; stone in the, 473, 488; 
surgical, 482, 485. 

Kidneys, 469, 473, 477; diseases of the, 477; 
hypera?mia of the, 477; normal, 55; 
palpation of the, bimanual, 477; position 
of the, 477; tuberculosis of the, 469, 
473. 

Kinking of the ureters, 469. 

Kissjel's treatment of noma, 245. 

Klotz, endoscope, 504; urethroscope, 504. 

Kneading of the abdomen, 597. 

Knee disease, 560, 587; treatment of, 588. 

Knife, tonsillar, use of the, 426. 

Knock knee, 589. 

"Koplik's spots," 198. 

Krukenberg pendulum apparatus, 591, 593. 
Kryoscopy. See Cryoscopy. 

Laboratory aids to clinical diagnosis, 17-56. 
Laceration of the perineum and cervix, 524, 
525. 

Lactometer, 118. 

Landry's paralysis, 706. 

Laryngismus stridulus, 212. 

Laryngitis, 152, 637; catarrhal, 415; chronic, 

415, 417; tuberculous, 420. 
Laryngoscopy and posterior rhinoscopy, 413. 
Laryngospasm, 212. 

Larynx, foreign bodies in the, 422; intuba- 
tion of, 186; neuroses of the, 428; oedema 
of the, 402, 426; of child two and a half 
years old, 188; paralysis of the muscles 



of the, 429; syphilis of the, 419; tumors, 
benign, of the, 421; vertigo of the, 429. 
Lathyrism, 828. 

Laudanum poisoning, treatment of, 826. 
Lavage, 60, 61, 62, 634; in vomiting of 

cholera asiatica, 634; of the stomach, 

61, 62. 
Law, Ohm's, 682. 
Law, Wolff's, 569. 
Laxatives in acute illness, 74. 
Lead salts poisoning, treatment of, 826. 
Leeching, 79. 

Leg, Barbadoes, 785; milk, 403. 

Legs, bow, 588. 

Lens, luxation of the, 815. 

Lentigo, 772, 804. 

Leontiasis ossea, 542. 

Lepra alphos, 780. 

Leprosy, 785, 786; anaesthetic, 786; non- 
syphilitic, 786; tuberculous, 785, 786. 

Leptomeningitis, 739, 740, 741, 742, 743. 

Leptomeningitis, acute, in adults, 739; 
aetiology of, 739; cerebral symptoms in, 
740; duration of the attack of, 740; in- 
fection through the arteries in, 739; 
pathology of, 739; symptoms of, 739; 
treatment of, 740; vomiting in, 740. 

Leptomeningitis, acute spinal, aetiology of, 
741 ; differential diagnosis of, 741 ; pa- 
thology of, 741 ; prognosis of, 741 ; symp- 
toms of, 741; treatment of, 741. 

Leptomeningitis, cerebral, 741. 

Leptomeningitis, chronic, in adults, 742; 
pathology of, 742; prognosis of, 742; 
symptoms of, 742; treatment of, 742. 

Leptomeningitis spinalis, chronic aetiology 
of, 742; differential diagnosis, 742; 
pathology of, 742; prognosis of, 743; 
symptoms of, 742; treatment of, 743. 

Leptothrix, 426; buccalis, 247. 

Lesions, 348-355, 815; clinical varieties of, 
545; destructive, of the sensory tract, 679; 
heart, 335, 348-355; heart, temperature in, 
15; in tuberculosis of the lungs, 451; 
kidney, diagnostic points in, 485; mis- 
cellaneous, in the brain, 751, 752; of the 
eye, 815; skin, in syphilis, 500. 

Lesions, valvular, baths, medicated, in, 353; 
digitalis treatment in, 355; principles of 
treatment of, 351, 352; pulse in, 348, 349; 
signs and symptoms of. 349 ; symptomatic 
management of, 353, 354. 

Lethargy, negro, 725. 

Leube and Riegel test dinner, 268. 

Leube's test, 267. 

Leucaemia, 46, 47, 377, 379; acute, 379; 
aetiology of, 377; blood in, 46; diagnosis of, 
379; lymphatic, 47, 378; mixed forms of, 
379; myelogenous, 46; prognosis of, 379. 

Leucaemia, splenomedullary, 673 ; cardiac 
symptoms in, 378; gastrointestinal symp- 
toms in, 378; pathology and symptoms 
of, 377; the blood in, 378; the ear in, 378; 
treatment of, 379, 380. 

Leucocytes, 44, 369, 372; classification of, 
369; counting, 44; counting, to dis- 
tinguish between appendicitis and typhoid 



854 



INDEX 



fever, 372; counting, to distinguish 
between pneumonia and typhoid fever, or 
malarial disease, 372; eosinophile, 369; 
pathological, 369. 

Leucocythaemia. See Leucaemia. 

Leucocytosis, 371; agonal, 371; ante- 
mortem, 371; cachectic, 371; classifica- 
tion of, Rieder's, 371; in cerebrospinal 
meningitis, 745; in tuberculous conditions, 
372; of acute infection, 371; pathological, 
371; physiological, 371. 

Leucoderma, 772. 

Leucorrhcea, treatment of, 521. 

Lice bites, treatment of, 829. 

Lichen ruber acuminatus, 779. 

Lichen ruber planus, prognosis and treat- 
ment of, 779. 

Lids, granular, 817. 

Life, change of, 518. 

Lipaeidaemia, 370. 

Lip? ma, 370. 

Lipoma, 791; congenital, 99. 
Liquor cerebrospinalis, 676. 
Lisping, 226. 
Lithaemia, 370, 643. 
Lithiasis, 322. 
Lithopaedion, 525. 

Litten's diaphragm phenomenon, 462. 

Little's disease, 96, 216. 

Liver, 313-320, 334; abscess of the, 318; 
abscess of the, treatment of, 318; amyloid, 
320; cancer of the, differential points of, 
319 ; chronic degenerative processes of the, 
320; cirrhosis of the, aetiology of, 317; 
cirrhosis of the, definition of, 317; 
cirrhosis of the, symptoms and diagnosis, 
317; cirrhosis of the, treatment, local, 
317; operative, 318; clinical pathology of 
the, 313; congestion of the, 316; conges- 
tion, treatment of, 316; corset, 314; disease 
of the, jaundice as a symptom of, 314, 
315; diseases of the, 313-320; floating, 
314; hydatid cysts of the, 320; lobed, 
314; nodulated hydatid, 320; size of the, 
in venous stasis, 334; syphilis of the, 
321. 

Liver spots, 772, 784. 

Localization, cerebral, familiar points in, 
681. 

Lock jaw. See Tetanus. 

Locomotor ataxia, 701, 702, 742; bladder 

and rectum, symptoms in, 702; crises of, 

702, 703; following diphtheria, 179. See 

also Ataxia. 
Lorenz method of reducing dislocation of 

hip, 584; details of, 584, 585. 
Lorenz spica, 582, 583. 
Loreta's operation, 105. 
Louse, pubic, treatment of, 829. 
Lousiness, 782. 
Lumbago, treatment of, 562. 
Lumbar puncture, 53. 

Lung, 36, 161, 432, 436, 445; abscess of the, 
432; abscess of the, diagnosis of, 432; ab- 
scess of the, prognosis of, 432; abscess of 
the, treatment of, 432; cirrhosis of the, 
446; emphysema of the, 445; gangrene of I 



the, 36, 161, 433; "spotted," 449; surgery 

of the, 457. 
Lungs, 161, 433, 445; haemorrhage from the, 

433; syphilis of the, 445. 
Lupinosa, treatment of, 828. 
Lupus erythematosus, treatment of, 791. 
Lupus vulgaris, treatment of, 788. 
Lye, treatment of poisoning by, 826. 
Lymph, 363, 364; massage as an aid to the 

circulation of, 597; nodes, enlarged, 171; 

stasis, 364. 
Lymphadenia, 380. 

Lymphadenitis, 364-367; acute, 365; acute, 

treatment of, 366, 367; chronic, 365; 

mediastinal, 468; retropharyngeal, 197; 

retropharyngeal, symptoms, diagnosis, 

and treatment of, 197, 198, 365. 
Lymphangeiectasis, 364. 
Lymphangeioma, 791; of the tongue, 249. 
Lymphangeitis, 364-367; symptoms and 

treatment of, 365. 
Lymphatic system, the, 363. 
Lymphocytes, 369. 
Lymphocytosis, 372. 
Lymphoma, simple hyperplastic, 365. 
Lymphomata, malignant, 366; syphilitic, 

366; treatment of, 366, 367; tuberculous, 

365. 

Lymphosarcoma, malignant, 380. 
Lyssa, 832. 

Madura foot, 783. 

Maidismus, 147; treatment of, 828. 

Main en griff e, 699. 

Malaria, 609; as a complicating factor in 
other diseases, 614; clinical varieties, 612, 
613; course and termination of, 612; 
diagnosis of, 612; differential diagnosis of, 
612; fever, 207; hot stage of, 611; in 
children, 207; in children, clinical types 
of, 207; infection in young children, 611; 
parasites of, 47; prophylaxis of, 610; 
quinine combination to prevent relapses 
of, 615; symptoms of, 611; tertian, 613; 
treatment of, 615. 

Mai de mer, 831 ; treatment of, 831. 

Malformation of the heart, congenital, 100. 

Malformations, and deformities, common 
forms of, 102-104; and deformities, rare 
forms of, 104-107; of the spinal cord, 766. 

Malnutrition (of infants), 142. 

Mai perforans, 796. 

Malposition of the uterus and ovaries, 523. 
Malum coxa? senile, 553. 
Marasmus, 142. 

Mark, birth, 95, 791 ; port wine, 791. 
Marriages, sterile, 507. 

Massage, 390, 596, 600; abdominal, 597; 
and movements in disturbances of the 
nervous system, 596, 597; as an aid to the 
circulation of blood and lymph, 597; 
familiar forms of, 596; for cedema, 390; 
of stiff joints, 598; treatment of the 
digestive and pelvic organs, 597; vibra- 
tion, in dyspepsia and catarrh of the 
stomach, 597; vibratory, 596, 600. 

Mast cells, 369. 



INDEX 



855 



Mastitis, 91. 
Mastodynia, 686. 
Mastoiditis, 809. 

Mastoid process, inflammation of the, 809; 
treatment of, 809. 

Masturbation, 506, 507, 520; in children, 
209, 506; in children, treatment of, 506. 

Maternal impressions, 106. 

Maternal nursing, 107. 

McKenzie tonsillotome, 193. 

Measles, 198, 199 ; complications and clinical 
varieties of, 200; differential diagnosis, 
prevention, prognosis, and treatment of, 
199, 200; German, 200, 201; important 
points to be noted for early recognition 
of, 199; peculiarities of the preemptive 
stage in, 198, 199; period of isolation for, 
604; pink eye of, 198. 

Meat, peptonized, 58. 

Mediastinitis, fibrous, 468. 

Mediastinum, affections of the, 468; affec- 
tions of the, treatment of, 468. 

Mediastinum, anterior, oedema of the, 402; 
emphysema of the, 468. 

Megaloblasts, 368, 374. 

Meiosis, 813, 815; bilateral, 815; spinalis in 
locomotor ataxia, 702. 

Meniere's disease, 810. 

Meningitis, 220, 221, 227, 738, 744, 748; 
cellular, 739; exudative, 739; Kernig's 
sign in, 222; onset of, 706; treatment in 
general of, 738. 

Meningitis cerebrospinalis in adults, aetiology 
of, 743; anomalous rases of, 745; boat- 
shaped abdomen of, 744; complications of, 
745; course of, 745; cranelike neck of, 
744; hydrocephalic cry of, 744; incubation 
period of, 744; leucocytosis in, 745; 
lumbar puncture in, 746; ordinary form 
of, 744; pathology of, 743; prognosis of, 
746; sequela? of, 746; symptoms of 
(malignant form), 744; treatment of, 746. 

Meningitis, cerebrospinal, in children, 222- 
227; antipyretic measures in, 223; diet in, 
223; prognosis of, 222; spinal puncture in, 
222; symptoms and signs of, in general, 
221 ; treatment of, 223, 224. 

Meningitis, chronic, in adults, 741 ; pathology 
of, 742; prognosis of, 742; symptoms of, 
742; treatment of, 742. 

Meningitis in adults, clinical varieties of, 
737; differential diagnosis of, 737; spinal 
puncture in, 738; symptoms and signs in 
general of, 737; treatment of, 738. 

Meningitis in children, simple acute, 220; 
Trousseau's sign in, 222; tuberculous, 
220, 221. 

Meningitis, tuberculous, in adults, 746; 

differential table of, 747; pathological 

changes in, 746; prognosis of, 747; 

symptoms of, 747; treatment of, 747. 
Meningocele, 765; and encephalocele, 98; 

spinal, 766; spurious, 98. 
Meningomyelocele, 766. 
Menopause, the, 518; haemorrhage during 

the, 518; premature, 518; treatment 

during the, 519. 
55 



Menorrhagia, 517. 

Menstrual condition of the average girl in 

health, 416. 
Menstrual disorders, 516. 
Menstruation, iregularities of, 376; vicarious, 

518. 

Mental defects from arrested development, 
228. 

Mental disturbances, 758. 
Mental suggestion for neurotic patients, 
726. 

Mental therapeutics and work for the sick 
83. 

Mercury, in syphilis, 499, 500; poisoning, 

treatment of, by, 826. 
Metatarsalgia, anterior, 589, 590. 
Meteorism, 287. 

Metric system in prescription writing, 86. 
Metrorrhagia, 517. 
Micrococcus tetragenus, 37. 
Microcytes, 368, 374. 
Microorganisms in sputum, 36, 37. 
Migraine, 285, 689. 

Miliaria, prognosis and treatment of, 779. 
Milium, 771. 

Milk, adapted, 114; breast, 40, 108, 109, 118, 
119; breast, contraindications for, 109; 
breast, how to influence the composition 
of, 110; certified, or guaranteed, 113; 
condensed, 116; contraindieated in dys- 
pepsia, 58; cow's, for infant feeding, 119; 
cow's, diluents of, 116; cow's, home 
modification of, 120; cure, 235; facts 
about, 113; goats' or asses', for infants, 
116; human, percentage of, 119; modified, 
114, 1 1 9 ; mother's, 107, 108; pancreatized, 
238; Pasteurized, 114; peptonized, 115; di- 
rections for peptonizing, 116; peptonized 
meat and, 58; Soxhlet's method of home 
sterilization of, 136; standard of cleanli- 
ness for, 113; sterilization of, rationale of, 
114; test for, 118; various changes in 
breast, 109. 

Milk filter, Seibert's aluminum, 1121. 

Milk food, 113-117; laboratories and pre- 
scription writing for, 118. 

Milk leg, 403. 

Milk poisoning, treatment of, 827. 

Mind, cure in nervous dyspepsia, 278; dis- 
eases of the, 725, 733. 

Miscarriage, prognosis of, 530; symptoms of, 
530; treatment of, 530. 

Mitchell, Weir, system, 239. 

Mole, 791. 

Mollifies ossium, 542. 

Molluscum contagiosum, 786. 

Monoplegia, 676. 

Morbilli, 198, 199, 200, 201, 604. 

Morbus Addisonii, 670, 671. 

Morbus maculcsus, 383. 

Morphine habit, treatment of, 830. 

Morphine poisoning, treatment of, 826. 

Mortality, infant, 107. 

Morton's painful affection of the foot, 589. 

Moth, 772. 

Motility and absorption of the stomach, 34. 
Motion, active, 596; passive, 596. 



856 



INDEX 



Motor, coordination, disturbances of, 678; 
dermatoneuroses, 796; phenomena, 676; 
power, 684. 

Mountain sickness, 832. 

Mouth, 88, 242, 243; care of, in the new- 
born, 88; diseases of, 242; dryness of, 
243. 

Movements, 596, 678; associated, 678; 
athetoid, 678; choreic, 678; forced, 678; 
quieting, 596; stimulating, 596; strength- 
ening, 596; Swedish, 596. 

Mucus, in stools, 28 ; in the urine, 22. 

Muguet, 127. 

Mumps, 128, 129. 

Murmurs, 334, 349 ; heart, 334; haemocardiac, 
349; spurious pulmonic, 349; systolic, 348. 

Muscle, 561, 562, 813; ciliary, paralysis of 
the, 813; contracture of, 562; degenera- 
tion of, 561 ; ossification of, 561 ; tumors of, 
562. 

Muscle fibres, 28, 561; fatty degeneration 
of, 561. 

Muscles, 553, 561, 562; atrophy of, 562; 
atrophy of, in arthritis deformans, 553; 
hypertrophy of, 562; injuries of, 561; 
pain in joints and, 14; rupture of, 561; 
sprains and strains of, 461. 

Mussel poisoning, treatment of, 827. 

Mustard bath, warm, for starting elimina- 
tion, 68. 

Mutism, 228. 

Myalgia, rheumatic, 562. 

Mycetoma, 783. 

Mycosis fungoides, 794. 

Mycosis of the pharynx, 426. 

Mydriasis, 812, 815. 

Myelitis, 704, 705; aetiology of, 705; course 
of, 705; disseminated, 705; diagnosis of, 
706 ; general, 705 ; pathology of, 705 ; symp- 
toms of, 705; transverse, 705; treatment 
of, 706; varieties of, 705. 

Myelocytes, 369. 

Myiasis, 829. 

Myocarditis, in rheumatism, articular, 549; 

with arrhythmia, 346. 
Myoclonia, 565; treatment of, 565. 
Myoma, 791. 

Myoma uteri, in married (middle life), 518; 

treatment of, 518. 
Myomata, uterine, 528. 
Myopathies, atrophic, 217; primary, 217. 
Myopia, 822. 

Myositis, 563; due to trichinosis, course, 
diagnosis, prognosis, and treatment of, 
564; ossificans, 564; purulent, acute, 564. 

Myotonia, 565; symptoms of, 565; treat- 
ment of, 565. 

Myringomycosis, 783. 

Myxcedema, 403, 664, 665; operative, 664; 
pathology of, 665; prognosis of, 665; 
symptoms of, 664; treatment of, 665, 
666 ; voice in, 664. 

Nsevi in young children, 95. 

Nsevus, 791, 792; araneus, 792; cavernosus, 

792; flammeus, 791; lipomatosus, 791; 

pigmentosus, 791; pilosus, 791; spillus, 



791; treatment of, 792; vasculosus, 791; 

verrucosus, 791. 
Nails, treatment of, 797, 798. 
Nasopharyngeal toilet, 80, 81 ; in diphtheria, 

81, 174; in diseases, and in reflex cough, 

81. 

Nasopharynx, examination of the, 412. 
Nausea, 73, 354; in cardiac failure, 354. 
Necrosis of the cartilages, 637. 
Nematodes, the, 31. 

Neoplasms, 295, 420, 479, 491, 789-793; 
benign, 789-793; benign and malignant, 
of the intestine, 295; of joints, 559; of 
the pharynx, 420; of the retroperitoneal 
glands, 491. 

Nephritis, 480, 481, 644; relation of albumi- 
nuria to, 472; uraemia in, 481. 

Nephritis, acute, 478; diet in, 479; enterocly- 
sis in, 479; prognosis of, 478; surgical 
treatment of, 481; symptoms of, 478; 
treatment of, 479. 

Nephritis, interstitial chronic, 480; diagnosis 
of, 22, 23; gout and, 644; prognosis of, 480; 
symptoms of, 480; treatment of, 480. 

Nephritis, parenchymatous, chronic, 479; 
diet in, 480; prognosis of, 479; symptoms 
of, 479 ; treatment of, 479. 

Nephritis, surgical, chronic, treatment of, 
481. 

Nephropexy, 485. 
Nephroptosis, 484. 

Nerve, 708, 711, 714, 820; clinic, the, 685; 
circumflex, paralysis of the, 714; musculo- 
spiral, paralysis of the, 713; optic, 
diseases of the, 820. 

Nerve palsies, 708-711. 

Nerve stretching, in sciatica, 688. 

Nerves, syphilis of the peripheral, 750; 
treatment of, 750. 

Nervous derangements, 725, 726; examina- 
tion scheme in, 683; familiar forms of, in 
children, 209, 210. 

Nervousness and insomnia in the absence of 
pain, 78. 

Nervous system, 675; gouty affections of 
the, 646, 647; sympathetic, 764. 

Neuralgia, 78, 282, 283, 685, 687; aetiology 
of, 685; cervicobrachial, 685; cervico- 
occipital, 685; digital, 685; Fothergill's, 
686 ; gastrointestinal , 282 ; gastrointestinal, 
differential points of, 282, 283; iliolumbar, 
517; inframaxillary, 686; infraorbital, 
685; intercostal, 686; lumbar, 517; 
lumboabdominal, 686; mammary, 686; 
Morton's, 687; of the rectum, treatment of, 
311; pain of, 78, 689; pedal, 688; plantar, 
687; supramaxillary, 686; supraorbital, 
685; symptomatic treatment of, 688; 
trigeminal, 686. 

Neuralgias, 685-688; general principles of 
treatment of, 687; of the male generative 
organs, 496; visceral, in heart disease, 
355. 

Neurasthenia, 726 ; aetiology of, 726 ; diagno- 
sis of, 727; heart, 356; primary, 726; sec- 
ondary, 726; symptoms of, 727; treat- 
ment, preventive, 727, 728. 



INDEX 



857 



Neuritis, 711, 713, 714, 758, 820; aetiology of, 
711; alcoholic, 713; course of, 712; 
differential diagnosis of, 714; diphtheritic, 
713; epidemic, 713; gouty, 713; multiple, 
550, 706; multiple, aetiology of, in 
autotoxic and toxic cases, 712; multiple, 
motor and sensory symptoms of, 712; 
multiple, symptoms of, 712, 713. 

Neuritis, optic, 820; optic, from tumor of 
the brain, 758; optic, treatment of, 821; 
paresis in, 219; pathology of, 711; 
peripheral, of diabetes, 655; prognosis of, 
714; symptoms of, 712; treatment of, 712, 
714. 

Neuroma, 791. 

Neurones, the, 675. 

Neuroses, 681, 730, 731; occupation, 691; 
of joints, 559; of the heart, 356; of the 
larynx, 428; of the male generative 
organs, 496; of the pharynx, 428; reflex, 
681; reflex, of nasal origin, 427; secretory, 
734; traumatic, aetiology of, 730; trau- 
matic, diagnosis of, 730; traumatic, prog- 
nosis of, 731 ; traumatic, symptoms of, 730; 
treatment of, 731; vesical, and irritability 
of the bladder 486. 

Neurosis, 278, 427; and paralysis of the 
upper respiratory tract, 427 ; secretory, of 
the stomach, 278; sensory, 428. 

Neurotic children. 210. 

New-born, 87, 92-102, 470; asphyxia in the, 
87 ; care of the, 87 ; care of the cord in the, 
87 ; care of the eyes in the, 88 ; care of the 
mouth in the, 88; clothing of the, 89; 
concrements, uric acid, in the kidney of 
the, 470; diseases of the, 92-102; jaundice 
of the, 315; oedema of the, 403; respiration 
of the, 88 ; stools of the, 89 ; temperature of 
the, 88 ; weight of the, 89. 

Nictitatio spastica, 210. 

Nightmare of children, 211. 

Nipple, Paget's disease of the, 794. 

Nipples, the care of, during nursing, 91. 

Nitrate of silver poisoning, treatment of, 826. 

Nitrous oxide and ethyl bromide as an 
anaesthetic, 823, 824. 

Nodding, head, 691. 

Nodes, Heberden's, 552, 553; lymph, en- 
larged, 171. 

Noma, 245; Kissjel's treatment of, 245. 

Normoblasts, 368, 374. 

Nose, 412, 418, 422, 423; anterior, examina- 
tion of the, 412; deformities of the, 423; 
foreign bodies in the, 422; new growths in 
the, 420; saddleback, 423; syphilis of the, 
418; tuberculosis of the, 419. 

Nurse, how to, 111. 

Nursery, the, 89. 

Nurses, points to be observed by, 89, 90. 

Nursing, maternal, 107; wet, 111. 

Nutrition and diet, 229. 

Nux vomica poisoning, treatment of, 826. 

Nymphomania, 521. 

Nystagmus, 210, 814; miners', 814. . 

Obesity, 296, 658, 659, 660; aetiology of, 658; 
anaanic, 659; diet for, 239, 659, 660; 



exercise in, 660; heredity of, 658; pa- 
thology of, 658; specimen diet in, 345;. 
symptoms of, 659 ; thyreoid treatment of, 
345; treatment of , 659. 
Obstipation, 283. 

Obstruction, 296, 323, 426; acute and 
chronic intestinal, 296; acute and chronic 
intestinal, differential points and treat- 
ment of, 296, 297; intestinal, from gall- 
stones, 323; nasal, 415, 416; respiratory, 
410; respiratory, causes of, 426. 

Occupation neuroses, 691. 

Odontomas, 539. 

Odontomata, 540. 

O'Dwyer's intubation set, 183. 

(Edema, 387, 390; acute, 399; acute, 
diagnosis and symptoms of, 399; acute 
pulmonary, prescriptions for, 355 ; adrena- 
lin chloride in, 181; angeioneurotic 
cutaneous, 404; bullosum, 406; collateral, 
402, 403; conjunctival, 402; following 
fracture, 404; from bites of insects, 402; 
general, 388; inflammatory, 387, 402, 403; 
in infants, 94, 95; in osteomyelitis, 535; 
malignant, 402; of Bright's disease, 388; 
of the anterior mediastinum, 402; of the 
eyelids, 564; of the foreskin, 402, 403; of 
the glottis, treatment of, 402; of the 
larynx, 426; of the larynx, treatment of, 
402; of the lower extremities, 389; of the 
new-born, 403; of the new-born, treat- 
ment of, 403 ; of the right hypochondrium, 
403; of the thorax, 403; of the uvula and 
soft palate, 402; of trichiniasis, 402; 
pulmonary, acute, 399, 400; pulmonary, 
aseptic ergot in, 401 ; pulmonary, sub- 
acute, inversion in, 401 ; scarification for, 
380; subacute, diagnosis and symptoms of, 
399; treatment of , with drugs, 389 ; unilat- 
eral, from thrombosis and pressure, 403. 

Oertel-and-Schwenninger system of diet, 
239. 

(Esophagus, 257, 258, 259; absence of the, 
257; acute inflammations of the, 258; 
anomalies of the, 257, 258 ; cancer of the, 
258, 259; diseases of the, 257; foreign 
bodies in the, use of Rontgen rays in the 
diagnosis of, 261; paralysis of the, 259, 
261; rupture of the, 259, 261; stricture of 
the, 259, 261 ; ulcers of the, 258, 259. 

Ohm's law, 682. 

Oidium albicans, 173. 

Oligocythemia, 370. 

Oliguria, 474. 

Omentum, cancer of the, 332 ; diseases of the, 

329. 
Omphalitis, 95. 

Onychatrophia, 797 ; treatment of, 798. 
Onychia, 797. 
Onychogryphosis, 798. 

Ophthalmia, 88, 818; gonorrhoeal, 818; 
neonatorum, 818; neonatorum, prevention 
of, 88; purulent, 818. 

Ophthalmic memoranda, 812. 

Ophthalmoplegia, 697; diagnosis of, 697; ex- 
terna, 697 ; interna, 697 ; progressive, 697 ; 
treatment of, 697. 



858 



INDEX 



Ophthalmoscope, the, 813, 815. 
Opium poisoning, treatment of, 826. 
Organs, respiratory, deep, 413; respiratory, 

disturbances of the, 411. 
Orchitis, 495. 

Orthopaedic memoranda, 569. 

Osmidrosis, prognosis and treatment of, 770. 

Osseous, muscular, and articular system 

and orthopaedics, 533-601. 
Ossification, of muscle, 561; of tendons, 568. 
Osteitis, 534, 541, 544; deformans, 541; 

rarefying, 534; syphilitic, 538. 
Osteoarthritis, 549, 551. 
Osteomalacia, 542; aetiology of, 542; course 

of, 543; diagnosis of, 543; prognosis of, 

543; symptoms of, 542; treatment of, 543. 
Osteomata, 539, 540. 

Osteomyelitis, 534; infectious, acute, diag- 
nosis of, 535; infectious, acute, pain of, 
535; infectious, acute, symptoms of, 535; 
tuberculous, diagnosis, prognosis, and 
treatment of, 537. 

Osteoperiostitis, 535; purulent, 535; simple, 
535; tuberculous, 536. 

Osteoporosis, 541. 

Osteosclerosis, 534. 

Otalgia, dental caries the cause of, 251. 

Otic memoranda, 806-811. 

Otitis, 205, 806, 807, 811; chronic purulent, 
ear drops for, 811; external, 807; media, 
806 ; media, catarrhalis, treatment of, 808 ; 
media, complicated with scarlet fever, 
205; media, purulent, acute, 808; treat- 
ment of, 808. 

Ovary, prolapse of, symptoms and treat- 
ment of, 524. 

Oxyuris, 30; vermicularis, 148. 

Pachydermia, 785; laryngis, 417. 

Pachymeningitis, 448, 748, 749; acute ex- 
ternal, prognosis and treatment of, 747; 
chronic internal, 747 ; externa spinalis, 448 ; 
hemorrhagic, 748; interna haemorrhagica 
spinalis, 748; interna hypertrophica spi- 
nalis, prognosis, pathology, symptoms, and 
treatment of, 748, 749; spinal, symptoms 
of, 748; spinal, treatment of, 748. 

Pack, cold, 67; cold, to the abdomen for 
insomnia, 731 ; hot, 66. 

Paederasty, 505. 

Paediatrics, 87-228. 

Paget's disease of the nipple, 794. 

Pain, as a symptom (in children), 14; 
diagnostic import of the seat of, 15; in 
acute and chronic illness, 78; in genito- 
urinary diseases, 470; in joints and 
muscles, 14; intermenstrual, 517; neck, 
685; neuralgic, 78; of colic, biliary, 488; 
of gastrointestinal neuralgia, 282 ; of 
osteomyelitis, acute infectious, 535; of 
tuberculosis, 450; side, 686; significance 
of fever and, 13, 14. 

Palisade worm, 492. 

Palpation, 292, 353, 354, 510-513; bimanual, 
in gestation, ectopic, 525; bimanual, of 
female pelvic organs, 510, 511, 513; in 
pleurisy with effusion, 162; of the ab- 



domen, 509; of the appendix vermiformis, 
292; of the Fallopian tubes, 513; of the 
pelvic organs, 597; rectoabdominal, 510. 

Palpitation (of the heart), 353, 354; in val- 
vular disease, treatment of, first and 
second and third stages of, 353, 354. 

Palsies, 105, 695, 708, 709 ; acute and 
chronic, 695; birth, 101; cranial nerve, 
708, 709; cranial nerve, treatment of, 708; 
fifth nerve, 709. 

Palsy, 693, 694, 709, 710; Bell's, aetiology of, 
709; Bell's, diagnosis of, 710; Bell's, pa- 
thology of, 710; Bell's, prognosis of, 710; 
Bell's, symptoms of, 709; Bell's, treatment 
of, 710; diagnosis of, 710; facial, 101 ; facial, 
aetiology of, 709; facial, pathology of, 710; 
facial, prognosis of, 710; facial, symptoms 
of, 709; facial, treatment of, 710; fourth 
nerve, 709 ; lead, gait in, 713 ; nuclear, 
710; seventh nerve, pathology of, 709; 
shaking, 693, 694; sixth nerve, 709; wast- 
ing, 698. 

Pancreas, 326, 327, 329; atrophy of the, 
326; chronic inflammation of the, 326; 
cysts of the, 326, 327; diseases of the, 324- 
329; gangrenous inflammation of the, 325; 
surgery of the, 329; tumors of the, 326, 
327. 

Pancreatitis, haemorrhagic, acute, 325; sup- 
purative, acute, 325. 
Pannus, 818. 

Papilloma, 792; congenital, of the larynx, 
421. 

Papillomata of the urethra, 494. 
Paracentesis, 811. 

Paraesthesia, 14, 15, 428, 701; in pain of 
locomotor ataxia, 701; of the pharynx, 
428. 

Paraldehyde poisoning, treatment of, 826. 
Paralyses of infancy and childhood, 216- 
219. 

Paralysis, 693, 706, 707; acute ascending, 
aetiology, pathology, symptoms, and 
treatment of, 706, 707; agitans, 693; 
agitans, aetiology of, 693; agitans, differ- 
ential diagnosis of, 694; agitans, progno- 
sis of, 694; agitans, symptoms of, 693; 
agitans, treatment of, 694; bulbar, aetiol- 
ogy of, 696; bulbar, symptoms of, 697; 
bulbar, treatment of, 696; cerebral, 677; 
cerebral, infantile, with retarded develop- 
ment, 217; choreic, 219; definition of, and 
four types of, 676; differential diagnosis 
of, 697; diphtheritic, 219; diver's, pathol- 
ogy, prognosis and treatment of, 708; due 
to disease of the nerves in the course of 
their distribution, 677; due to muscular 
disease, 677; Erb's, 101; glossolabiolaryn- 
geal, 697; glossolabiolaryngeal, aetiology 
of, 697; glossolabiolaryngeal, symptoms 
and treatment of, 697; hypoglossal (twelfth 
nerve), 711; hysterical, 429; infantile, 591; 
Landry's, 706; lead, 713; muscular, in com- 
pression of the brain, 756; muscular, pseu- 
dohypertrophic, 217, 218; muscular, pseu- 
dohypertrophic, treatment of, 218, 219; 
obstetrical, 216; of the bladder, 487; of the 



INDEX 



859 



ciliary muscle, 813; of the circumflex 
nerve, 714; of the muscles of the larynx, 
429; of the musculospiral nerve, 712; of 
the musculospiral nerve, aetiology of, 714; 
of the oesophagus, 259, 261; of the soft 
palate in diphtheria, 179; of the third 
nerve, 813; of the upper respiratory tract 
427; painful, of young children, 219; pneu- 
mogastric (tenth nerve), 711, 712; Pott's, 
219; spastic spinal, 700; spinal, 677; spinal 
accessory (eleventh nerve), 711; spinal, in- 
fantile, 216, 217; spinal, infantile, treat- 
ment of, 217; syphilitic, of peripheral 
origin, 219. 

Paraphimosis, 403, 493. 

Paraplegia, 676, 728; ataxic, 704; spastic, 
677. 

Parasites, 47, 298, 299, 300, 609, 762; in- 
testinal, 298-301; intestinal, common and 
rare forms of, 298, 299; intestinal, treat- 
ment of, 299, 300; malarial, 47, 609; of 
the brain, 762; of the genitourinary tract, 
492. 

"Paratyphoid" bacillus, 48. 
Paratyphoid fever, 616. 
Paregoric poisoning, treatment of, 826. 
Paresis, and paralysis, 676; in neuritis, 219; 

of the intestine, 284, 296. 
Paris green poisoning, treatment of, 826. 
Parkinson's disease, 693. 
Parotitis, 128, 129. 
Paroxysms, malarial, 613. 
Parry's disease, 667. 
Pavor nocturnus et diurnus, 211. 
Pediculi, pubis, 492; treatment of bites 

from, 829. 

Pediculosis, 782; capitis, 787; corporis, 782; 
pubis, treatment of, 782. 

Peliosis rheumatica, 382, 384. 

Pellagra, 147; treatment of, 828. 

Pelvis, female, benign and new growths of 
the, 527 ; inflammation of the, clinical 
varieties of, 526. 

Pemphigus, 774, 779; foliaceus, 779; gan- 
granosus, prognosis and treatment of, 774; 
neonatorum, 779 ; neonatorum syphili- 
ticus, prognosis and treatment of, 779; 
simplex, 779; syphiliticus, 500; vulgaris 
in infants, 94. 

Penis, the, 492; inflammation of the glans, 
493. 

Penzold and Faber, method of, for gastric 

resorption, 268. 
Peptone in the urine, 20. 
Peptonoids, beef, 58. 

Percussion, 163, 270, 450; in pleurisy with 
effusion, 163; in tuberculosis, 450; of the 
abdomen, 270. 

Perforation of the intestine in typhoid fever, 
625. 

Pericarditis, 341, 342, 549; definition and 
aetiology of, 341; dry, 341; in rheumatism, 
articular, 549; suppurative, 343; treat- 
ment of, 342; with adhesions, symptoms 
and treatment of, 343; with effusion, 341; 
with effusion, physical signs of, 342. 

Pericardium, adherent, 343. 



Pericardium, dropsy of the, 342. 
Perichondritis laryngis, 415. 
Pericystitis, 487. 
Perinaeum, laceration of the, 524. 
Periostitis, syphilitic, 538. 
Peritonaeum, cancer of the, 332; diseases of 
the, 329. 

Peritonitis, 329-332; acute, 329, 330; acute, 
treatment of, 330; chronic, 331; clinical 
varieties of, 329; in typhoid fever, 625; 
subphrenic, 331; tuberculous, 332; tuber- 
culous, clinical varieties of, 150; tubercu- 
lous, in children, 149. 

Peritonsillitis, 191. 

Perlesche, 250. 

Pernio, prognosis and treatment of, 774. 
Pertussis. See Whooping Cough. 
Pest, 641. 

Petit mal, 723; from tumor of the brain, 
758. 

Pharyngitis, acute, 415; chronic, 415; chron- 
ic, 416, 417; chronic, hypertrophic form, 
417; granular, in children, 153; in children, 
152. 

Pharynx, mycosis of the, 426; neoplasms of 
the, 420; neuroses of the, 428; syphilis of 
the, 419; ulcers of the, 419. 

Phenomena, miscellaneous, 685; motor, 676; 
motor, of the intestine, 269; motor, of the 
stomach, 262; secretory, sensory, and 
special sense, 679; sensory, of the intes- 
tine, 270; sensory, of the stomach, 263. 

Phimosis, 103, 493. 

Phlebitis, 361; septic, 361. 

Phlegmon of the neck, 425. 

Phosphorus poisoning, treatment of, 826. 

Photophobia, 812. 

Phthisis, 446; fibroid, 450. 

Picric acid test for urine, 19. 

Picrotoxin poisoning, treatment of, 826. 

Pigmentation, 671, 772; anomalies of, 772; 
of the skin in Addison's disease, 671. 

Pigments, poisoning of, 828. 

Piles. See Hemorrhoids. 

Pimples (acne), 771. 

Pinworms, 30, 148. 

Pipettes, Thoma-Zeiss, 43. 

Pityriasis, 780; pilaris, 780; prognosis of, 
780; rosea, 780; rubra, 780. 

Placebos, 84. 

Plague, bubonic, 641, 642. 
Plasma, blood, 369. 

Plasmodium malaria, examination of the 
blood for, 15, 44. 

Plasmon, 238. 

Plethora, 369; serosa, 370. 

Pleurisy, 162, 166, 369, 438, 460, 461, 463, 
464; acute, 460; chronic, 464; chylous, 
462; diaphragmatic, 462; different forms 
of, 460; dry, 461; dry, treatment of, 462; 
effusive, 461; encysted, 462; fibrinous, 
461; hsemorrhagic, 462; hyperinosis in, 
369; in children, treatment of, 166; plas- 
tic, 461; pulsating, 462; purulent, 438, 
462; serofibrinous, 461; subacute, 162; 
wet, 461; wet, physical signs of, 461; wet, 
prognosis of, 461. 



860 



INDEX 



Pleurisy, with effusion, 159, 160, 464; fever 
in, 162; operating for, 396, 397; palpa- 
tion in, 162; percussion in, 163; treatment 
of, 463, 464. 

Pleuropneumonia, fibrinous, 438. 

Pleuropneumonia, in children, auscultation, 
diagnosis, palpation, percussion, puncture, 
and treatment of, 160-166. 

Pneumococcus, 42; lanceolatus, 220. 

Pneumoconiosis, 445; duration of, 445; 
general characteristics of, 445; treatment 
of, 445. 

Pneumonia, 157, 159, 435, 446, 625; and 
iodophilia, relation of, 49, 50; acute lobar, 
in children, clinical varieties, conditions, 
pain, symptoms, treatment of, 157, 159; 
catarrhal, 153, 435; chronic interstitial, 
445, 446; complicated with typhoid fever, 
625; croupous, 157; fever in, 167; fibrinous, 
157, 438; fibrinous, stage of red hepatiza- 
tion of, 438; hyperinosis in, 369; prune- 
juice expectoration in, 36; rusty sputum 
in, 35; tuberculous, 14; unresolved, 14. 

Pneumonia, lobar, 438-442; auscultation in, 
439; clinical varieties of, 440; cough of, 
439; differential points of, 440; pain in, 
439; physical signs of, 439; predisposing 
factors of, 439; prognosis of, 440; palpa- 
tion in, 439; respiration in, 440; sputum 
of, 439; treatment of, 441. 

Pneumonitis, fibrinous, in adults, 438. 

Pneumopericardium, 342. 

Pneumothorax, 464, 465; causes of, 465; 
characteristics of, 465; differential points 
of, 465; signs, 465; summary for, 466; 
treatment of, 466; use of Sauerbruch's 
air chamber in, 466. 

Podagra, 643. 

Podalgia, 687. 

Poikilocytes, 368, 374. 

Poisoning, 825, 826, 278; blood. See Septi- 
cemia ; systemic, from kidney insuffi- 
ciency, 471; to provoke vomiting in, 825; 
treatment of, 825, 826, 827. 

Poisons and antidotes, 825. 

Poisons, various, and their treatment, 828 
829. 

Poliomyelitis, anterior acute, 216, 217; 
differential diagnosis from lateral sclerosis, 
700; in adults, 698; subacute chronic, 698; 
symptoms of, 590. 

Pollantin Dunbar, 427. 

Pollen fever, 427; treatment of, 428. 

Pollution, 505, 500. 

Polyarthritis, chronic, 551. 

Polychromasia, 370. 

Polycythaemia, 370. 

Polyphagia, 263. 

Polypi, 308, 420, 527; rectal, 308; uterine, 
527. 

Polyps, of the nose, 420; of the middle ear, 
809; of the urethra, 494; symptoms, 420. 
Polypus, removal of, 95. 
Polyuria, 470, 471, 474. 
Porencephaly, 765. 
Posture, 533. 

Potash poisoning, treatment of, 826. 



Potassium chlorate poisoning, treatment of, 
826. 

Potassium cyanide poisoning, treatment of, 
826. 

Pot belly of rhachitic children, 144. 

Pott's disease, 569; complications of, 574; 
diagnosis and symptoms of, 570, 571; 
occurrence of, 569; spasmodic contrac- 
tion of the limbs in, 574; therapeutics of, 
572; treatment, general hygienic, of, 574. 

Practical approximate gramme values, 86. 

Precipitins, 54. 

Pregnancy, treatment during, 720, 721. 
Presbyopia, 822. 

Prescription blank for milk food, 117. 
Prescription writing, metric system in, 86. 
Priapism, 493, 505. 
Prickly heat, 779. 
Proctitis, 289, 304. 
Proctospasm, 269. 

Prolapse, 485, 523, 524; of the bladder, 524; 
of the ovary, 523; of the ovary, symptoms 
and treatment of, 524; of the rectum, 309; 
causes, treatment of, 309; of the uterus, 
523; of the uterus, symptoms and treat- 
ment of, 524; sacculated, of the right ure- 
ter, 485. 

Prolapsus ani in children, treatment of, 
309. 

Prolapsus ventriculi, 418. 

Prophylaxis and disinfection, 603. 

Prosopalgia, 686. 

Prostate, hypertrophy of the, 494. 

Prostatism, without enlargement, 494; 

acute, 494; acute, causes of, 494, 495; 

acute, treatment of, 495; chronic, 495; 

chronic, stripping the seminal vesicles for, 

495. 

Protozoa and bacteria in the faeces, 29. 
Prurigo mitis, 780; prognosis and treatment 
of, 780. 

Pruritus, 308, 795; ani, 308; ani, treatment 
of, 308; treatment of, 795. 

Pseudodiphtheria, 172, 191. 

Pseudoelephantiasis ,771. 

Pseudoleucaemia, 380 ; retiology of, 380 ; 
blood changes in, 380; diagnosis and prog- 
nosis of, 381 ; pathology of, 380; symptoms 
of, 380; treatment of, 381. 

Pseudoleucocythamia, 380. 

Pseudomembrane, 194. 

Pseudoparalysis, 219. 

Pseudorheumatism, 562. 

Pseudotetanus. See Tetany. 

Psoriasis, 780; circinata, 780; diffusa, 780; 
guttata, 780; gyrata, 780; nummulata, 
780; prognosis and treatment of, 782. 

Ptomaine poisoning, treatment of, 827. 

Ptosis, 813; morning, or waking, 813; treat- 
ment of, 817. 

Pulpitis-periostitis, remarks on, 255. 

Pulse, Corrigan's, 348; in coma, 719; in con- 
vulsions, puerperal, 717; in tumor of the 
brain, 758; in venous circulation, 360; in 
yellow fever, 627. 

Pulse of the new-born, 88; water hammer, 
348. 



INDEX 



861 



Puncture, 53, 394, 398, 407, 746; cranial, 
398; exploratory, in special examinations, 
16; exploratory, of the chest, 394; explora- 
tory, of the female pelvic organs, 515; 
fluids, examination of, 407; lumbar, 53, 
407, 746; lumbar, in cerebrospinal menin- 
gitis, 746; lumbar, method of procedure 
in, 746; points of, 407; spinal, in cerebro- 
spinal meningitis, 222, 223; spinal, in hy- 
drocephalus, 398, 399. 

Punctures, diagnostic, 407, 408. 

Punctures, technique of, 407. 

Pupil, Argyll Robertson, 815. 

Pupils, the, 814, 815. 

Purpura, 382; clinical varieties of, 382; hem- 
orrhagica, 382; hemorrhagica, acute or 
fulminating, 383; hemorrhagica, He- 
noch's, 383; hemorrhagica, infectious, 
382; hemorrhagica, severe forms of, 383; 
hemorrhagica, toxic, 382; pathological 
varieties of, 382; rheumatica, 382; simplex, 
382, 384; treatment of various kinds of, 
384 

Pus, 25, 26, 28, 91, 474; casts, 25; in stools, 
28; in the breast (of a nursing mother), 
91; in urine, 26, 474; test for, in the 
urine, 26. 

Pustulosa, 771. 

Putrefaction, intestinal, 301, 302. 

Pyemia, 370, 385, 612; from osteomyelitis 

of the long bones, 549. 
Pyelitis, 482, 483, 487; complicated with 

typhoid fever, 625; differential points of, 

483; symptoms of, 482; treatment of, 

483. 

Pyelonephritis, symptoms and treatment of, 

482, 483. 
Pylephlebitis, suppurative, 318. 
Pylorus, congenital hypertrophic stenosis of 

the, 104. 

Pyogenic diseases, hypinosis in, 369. 

Pyonephritis, 482. 

Pyonephrosis, 328, 404. 

Pyopneumothorax, 161, 465. 

Pyorrhoea, alveolar, 255. 

Pyothorax, 161, 464; in children, multiloc- 
ular, 165; in children, treatment of, 166; 
right-sided, 318; significance of fever fol- 
lowing operation for, 167; temperature 
after operation, 168. 

Pyuria, 474. 

Quinine, sweet, in malaria, 615. 
Quinsy, 191, 192, 424. 

Rabies, 832. 
Ranula, 249. 

Rash, of measles, 203; of rubella, 200; of 
scarlet fever, 203, 204; of typhus fever, 
629. 

Raynaud's disease, etiology of, 734, 796; 
diagnosis and treatment of, 736. 

Rays, Rontgen. See X Rays. 

Reaction, "hydrotherapeutic," 65; of de- 
generation, 682; of urine, 18; Widal, 47. 

Reagent, Toepfer's, 32. 

Records of cases, value of keeping, 833-838. 



Rectal alimentation, 59. 

Rectum, 304, 310, 311; catarrh of the, 304; 
examination of the, 304; fissure and ulcer 
of the, 309; fissure and ulcer of the, treat- 
ment of, 310; neuralgia of the, treatment 
of, 311. 

Reflexes, 679, 680; organic, 679. 

Regurgitation, mitral, 349; tricuspid, 350. 

Resorcin poisoning in an infant, 112. 

Resorption, gastric, test for, 268. 

Respiration, 12, 88, 93, 410; failure of, in the 
new-born, 93; internal, 410; of the new- 
born, 88; organs of, 12; tissue, 410. 

Respiratory obstruction, 426. 

Respiratory system, the, 468. 

Respiratory tract, deep, 431; upper, 409- 
411; upper, erosions and ulcers in the, 418; 
upper, examination of the, 411; upper, 
neurosis and paralysis of the, 427; upper, 
new growths of the, 420. 

Rest cure, out of door, 454, 455. 

Retina, detachment of the, 820; diseases of 
the, 820. 

Retinitis, 820; albuminuric, 820; hemor- 
rhagic, 820; syphilitic, 820. 

Retractor, automatic tracheal (Caille), 189. 

Retroflexion of the uterus, treatment of, 
523, 524. 

Retroversion of the uterus, 523; treatment 

of, 523, 524. 
Rhachischisis posterior, 766. 
Rhachitis, 142, 143. 

Rheumatism, 369, 549, 550, 551; alkaline 
treatment for, 550, 551; articular, acute, 
547, 548; articular, acute, etiology of, 
548; articular, acute, course and compli- 
cations of, 548; articular, acute, exciting 
causes of, 548; articular, acute, symptoms 
of, 548. 

Rheumatism, articular, hyperinosis in, 369; 
articular, subacute, hot air treatment in, 
551; cerebral, 549; chronic, 556; chronic, 
and arthritis deformans, differential diag- 
nosis between, 555; chronic muscular, 
vibratory treatment in, 600; diet in, 551; 
Fuller's alkaline treatment in, 550; in 
children, course, termination and treat- 
ment of, 550, 551; in children, manifesta- 
tions of, 550; local treatment of, 551; 
monarticular, 550; muscular, treatment 
of, 562; with hyperpyrexia, complicating 
features, diagnosis, and differential points 
of, 549; with hyperpyrexia, local treat- 
ment of, 551. 

Rhinitis, 415, 418, 430; acute, formule for, 
430; atrophic, 418; chronic, 415; hyper- 
trophic, 416; hypertrophic, diagnosis of, 
416; hypertrophic, treatment of, 416; 
simple acute, in children, 152; vasomotor, 
427. 

Rhinoliths, 52, 422. 

Rhinoscleroma, 786. 

Rhus toxicodendron, 775. 

Rhus venenata, 775. 

"Rice bodies," 406, 567. 

Rice water stools of cholera, 633. 

Ricinus siccol, 74. 



862 



INDEX 



Rickets, 143, 146; clinical forms of, 144; 
fat, 144; muscle, 144; prophylaxis and 
treatment of, 144, 145; spinal curvature 
of, 571. 

"Rider's bone," 561. 

Rieder's classification of leucocytosis, 371. 

Riegel and Leube's test dinner, 268. 

Riga's disease, 127, 247. 

Rigidity, congenital (Little's disease), 96. 

Ringworm, 783. 

Romberg's sign, 814. 

Rontgen rays in examination of bony 

structures, 16, 535. 
Rotheln, 200. 
Round worm, 30, 31, 148. 
Rubella, rash of, 200. 

Rules for converting apothecaries' weights 
and measures into the metric system, 86. 

Rules to prevent the spread of vulvovagi- 
nitis, specific, 609. 

Running, paroxysmal, in children, 209. 

Rupia syphilitica, 498. 

Rupture, 259, 261, 477, 557; of tendons, 
symptoms and treatment of, 566, 567; of 
the bladder, 486; of the kidney, 477, 478; 
of the oesophagus, 259, 261. 

Saccharometer, Einhorn's, 21. 
Sahli's test, 34, 35. 

Saline infusion in shock and haemorrhage, 

70, 71. 
Salt rheum, 776. 

Sarcoma, 319, 491, 794; cutaneous, general, 
794; idiopathic, 794; melanotic, 794; 
multiple, 794; of the kidney, 491; pig- 
mented, 794; primary, 319, 794; second- 
ary, 319; treatment of, 422, 795. 

Sarcomata, 529, 540, 757; diagnosis of, 
541. 

Sarcopeptones, 58. 

Sarcoptes scabei, 783. 

Sauerbruch's air chamber, 466. 

Scabies, prognosis and treatment of, 782. 

Scall, 776. 

Scar, 789. 

Scarification, for oedema, 390; in local 
hyperaemia and congestion, 79. 

Scarlatina, exfoliating dermatitis in, 204. 

Scarlet fever, 201-206; differential diag- 
nosis in, 203; fatal septic form of, 204; 
haemorrhagic form of, 204; incubation 
period of, 202; mild form of, 204; mor- 
tality of, 202; nephritis and dropsy follow- 
ing, 206; nervous symptoms of, 205; nose 
and throat in, local treatment of the, 205; 
onset and symptoms of, 203, 204; period 
of isolation for, 604; sloughing in, 206; 
strawberry tongue of, 203; swollen joints 
in, 205; symptoms, complications, and 
sequelae of, 204, 205; torticollis following, 
205; treatment of, 204. 

Scheele's green poisoning, treatment of, 826. 

Schizomycetae, 784. 

"Schluckgerausch," the, 268. 

Schoenlein's disease, 382. 

Schweninger and Oertel systems of diet, 
239. 



Sciatica, 687; nerve stretching in, 688J 
treatment, general, of, 688. 

Sclerema and cedema in infants, 94; prog- 
nosis and treatment of, 781. 

Scleritis, 819. 

Sclerosis, 704, 707, 708; amyotrophic later- 
al, prognosis of, 700; amyotrophic lateral, 
symptoms of, 700; amyotrophic lateral, 
treatment of, 700; cerebrospinal, aetiol- 
ogy of, 707; cerebrospinal, course of, 708; 
cerebrospinal, diagnosis of, 708; cerebro- 
spinal, pathology of, 707; cerebrospinal, 
symptoms of, 707 ; combined, 704; dis- 
seminated, 707; lateral, differential diag- 
nosis from anterior poliomyelitis (Starr), 
700; multiple, 707; secondary lateral, 701. 

Scoliosis, 578. 

Scorbutus, 661. 

"Scratch band" of Lorenz, 574. 

Scrofuloderma, 788; treatment of, 788. 

Scurvy, 142, 549; in adults, definition of, 
661; in adults, diagnosis and symptoms 
of, 661, 662; in adults, differential points 
of, 662; in adults, mortality of, 661; in 
adults, prognosis of, 663 ; in adults, 
prophylaxis of, 663; in adults, treatment 
of, 663; in children, 145; in children, 
symptoms of, 147; in children, treatment 
of, 147. 

Seasickness, treatment of, 831. 

Seat worm, 148. 

Seborrhcea oleosa, 772. 

Seborrhoea sicca (general), 94. 

Seibert's milk filter, 121. 

Sensation, delayed, 795. 

Sepsis, hypinosis in, 369. 

Sepsis, puerperal, 531, 532. 

Septicaemia, 370, 385; symptoms of, 385; 

treatment of, 386. 
Serum, 369 ; culture for diphtheria, 55 ; 

therapy in tetanus, 53, 833 ; therapy in 

fever, relapsing, 632. 
Shingles, 777. 

Shock, 338, 339; saline infusion in, 70. 

Sickness, feeding in, 50-60 ; sleeping, 725 ; 
mountain, 832. 

Side chain hypothesis, 53. 

Sight, sense of, 812, 821. 

Sign, Bacelli's, 162; Kernig's, in meningitis, 
222; Romberg's, 814; Trousseau's, in 
meningitis, 222; Von Graefe's, in Base- 
dow's disease, 668. 

Simon's test for haematoporphyrin in the 
urine, 24. 

Singultus, 269. 

Sinuses, disease of the accessory, of the nose, 
424* treatment 424. 

Skin, 496, 647, 671; actinomycosis, 782, 783; 
bronzing of the, 671, 769; carcinoma of 
the, 793; chafing of the, 771; color of, 769; 
diseases of the, 769, 770, 782; goose, 796; 
gouty affections of the, 647; inflammations 
of the, 772; manifestations of the male 
generative organs, 496 ; secretory function 
of the, 769; sensory function of the, 769. 

Sleeping sickness, aetiology, symptoms, and 
treatment of, 725. 



INDEX 



863 



Sleeplessness. See Insomnia. 
Slobbering, 243; of infants, 126. 
Sloughing, in scarlet fever, 205. 
Smallpox, 637, 638. 

Smallpox, discrete, and chickenpox, distin- 
guishing characteristics between, 638; 
hemorrhagic, 637. 

Snake bites, treatment of, 829. 

Snare, Jarvis's, 421. 

Snuffles, in the new-born, 93. 

Solution, decinormal, NaOH, 31. 

Somatose, 238. 

Sordes, 250. 

Sounds, heart, 334; pericardial friction, 334; 
pleuritic friction, in tuberculosis, 447. 

Spasm, 429, 691; habit, 209, 210, 691; nictat- 
ing, 814; of the oesophagus, 261; phonet- 
ic, 429; rhythmical, 814; saltatory, 693; 
sewing, 692; winking, 814. 

Spasms, 678; clonic, 210. 

Spasmus glottidis, 429. 

Spasmus nutans, 210. 

Speech, disorders of, 226; scanning, 708. 

Sphaceloderma, 796. 

Spica, Lorenz, 582, 583. 

Spina bifida, 102, 766. 

Spinal puncture in cerebrospinal meningitis, 
222, 223. 

Spine, lateral curvature of the, 576; lateral 
curvature of the, aetiology of, 577; rigid, 
symptoms and treatment of, 579. 

Splanchnoptosis, 300; clinical features and 
treatment of, 300, 301. 

Spleen, 673; dulness of, 673; general remarks 
on the, 673; malarial, 673; movable, 673. 

Spondylitis deformans, symptoms and treat- 
ment of, 579. 

Spondylose rhizomelique, 579. 

Spots, Koplik, 198; liver, 772, 784. 

"Spotted" lung, 449. 

Sprains, 545; diagnosis of, 545; treatment 
of, 545, 598. 

Sputum, 36, 37, 618; coin-shaped (nummu- 
lar), 36; disinfection of, in typhoid fever, 
618; gross, characteristics of, 35, 36; mi- 
croorganisms in, 36; microscopic examina- 
tion of, 36, 37; nummular, 36. 

Squamosa neonatorum, 94. 

Squint, 814, 821. 

Stagnation of the stomach, 264. 

Stagnation of urine (from stricture), 468. 

Stammering, 226, 691. 

Staphylococcus aureus, 41. 

Stasis, 334, 335, 364, 426; lymph, 364; 
oedema, 426; venous, 335; venous, size of 
the liver in, 334. 

Status epilepticus, 722. 

Status vertiginosus, 715. 

Stellwag's symptom in Basedow's disease, 
668. 

Stenosis, 187, 348, 417; acute progressive, 
diphtheria antitoxine in, 181; aortic, 348; 
complete, rapid tracheotomy in, 187; 
congenital hypertrophic, of the pylorus 
and duodenum, 104; congenital pharyn- 
gooesophageal, in infants, 105; mitral, 
350; nasal, 417; of the oesophagus, 258; 



pulmonic, 351; rectal, in infants, 102; 
tracheal, 427; treatment and diagnosis of 
congenital pyloric, in infants, 105; tri- 
cuspid, 350. 

Sterility, in the female, causes of, 519, 520; 
in the male, 506. 

Sterilization of milk, Soxhlet's method of 
home, 136; rationale of milk, 114, 115. 

Stigmata of degeneration, 106, 767. 

Stimulants and beverages, 236, 237. 

Stimulation, drug, 71; in circulatory failure, 
69, 70; vibratory, 600. 

Stings of insects, treatment of, 829. 

Stomach, 34, 264, 280, 282, 283; absorption 
and motility of, 34; amount of HC1 in the, 
34; anacidity of the, 264; cancer of the, 
differential diagnosis of, 280, 281; chem- 
ical analysis of contents of the, 32, 33, 268; 
clinical pathology of the, and intestine, 
263; cramps of the, 282; diagnostic tech- 
nique of the, 266, 270; dilatation of the, 
276, 277; erosions and ulcer of the, 279; 
haemorrhage from the, 281, 282; hyper- 
acidity of the, 264; injuries of the, 264; 
method of testing the motor function of 
the, 267; microscopic examination of the, 
32; motor phenomena and neuroses of the, 
262; operations on the, indications for, 
283; secretory neuroses of the, 263, 264, 
278; sensory phenomena of the, 263; 
stagnation of the, 264; stricture of the, 
gastroenterostomy for, 283; syphilis of 
the, 281; test for lactic acid in, 34; test- 
ing contents of the, 33 ; transillumination 
of, with fluorescein, 266; tube, contrain- 
dications for using the, 61; tube, feeding 
by the, 61; ulcer of the, 279; washing of, 
in adults, 61; washing of, in children, 62; 
washing of, in obstinate vomiting of 
cholera infantum, 62; x ray examination 
of the, 267. 

Stomatitis, 126, 244, 246, 247; catarrhalis, 
244; croupous, 246; diphtheritica, 246; 
follicularis (aphthous or vesicular form), 
244; gangraenosa, 245; gonorrhoica, 246; 
membranous, 246, 247; syphilitica, 246; 
tuberculosa, 246; ulcerosa, 244. 

Stools, 29, 30, 271, 633; bacteria in, 29, 30; 
blood in, of typhoid patients, 271; Char- 
cot-Leyden crystals in, 29; epithelial cells 
in, 28; mucus in, 28; pus in, 28; rice water, 
of cholera, 633; typhoid, 27. 

Stovaine (a local anaesthetic), 825. 

Strabismus, 814, 821; alternating, con- 
comitant, constant, convergent, 814; 
paralytic, 814; treatment of, 821. 

Stramonium poisoning, treatment of, 827. 

Strangulation of the intestine, 296. 

Strawberry tongue, 203. 

Streptococcus, 41; pyogenes, 29. 

Streptothrix actinomyces, 445. 

Stricture, 93, 259, 261, 493; of the oesopha- 
gus, 259, 261; of the stomach, 283; of the 
urethral canal, 493, 494; spasmodic, in 
infants, 105; ulceration and, of the rec- 
tum, 310, 311. 

Stridor, congenital, in the new-born, 93. 



864 



INDEX 



Strongulus gigans, 492. 

Strophulus, 779; albidus, 771. 

Strychnine poisoning, treatment of, 826. 

Stuttering, 226. 

St. Vitus's dance, 215. 

Sty, treatment of, 816. 

Sudamina, 779. 

Suggestion, mental, for insomnia, 732; men- 
tal, in seasickness, 831; mental, method of, 
732, 733. 

Suggestion therapy, in asthma, 460. 

Sunburn, 773, 803. 

Suppressio mesium, 516. 

Suppression of urine, 476. 

Suppuration, pelvic, in women, 526, 527. 

Suprarenal extract (externally and locally) 
for hemophilia, 385. 

Suprarenal gland, 670. 

Surgery, lung, 457; of the pancreas, 329. 

Sweat, bloody, 770; colored, 770. 

Sweat glands, diseases of, 770. 

Sweating, 769; of anasarca, 389. 

Swelling, white, differential diagnosis of, 
588; symptoms of, 587. 

Swellings, cedematous, 387. 

Sycosis, 783. 

Symptoms, grouping and recognition of, 11, 
12. 

Syncope, local, 734, 796. 

Synovitis, 546; acute, 546; chronic, 546; 
purulent, 546. 

Syphilis, 497, 498; cerebral, 749; hereditaria 
tarda, 501; hereditary, 501; hereditary, of 
the brain, 750; in adults and children, 498; 
in hydrocephalus, 224; in infants, acquired 
form of, 500; in infants, congenital form 
of, 500; in infants, inherited, 500; initial 
lesion of, 498; instructions to those having, 
499; inunction cure for, 499; of bone, 538, 
539; of the genitourinary tract, 490; of the 
larynx, 419; of the lungs, 445, 446; of the 
nervous system, 749; of the nose, 418; of 
the peripheral nerves, 750; of the pharynx, 
419; of the skin, 786, 788; of the skin, ter- 
tiary, 498, 787; of the stomach, 281; pro- 
phylaxis of, 497, 498, 499, 501; spinal, 
750; transmitting, 498; treatment of, 499, 
500. 

Syringomyelia, 707. 
Systems of diet, 239. 

Tabes, diabetic, 655. 

Tabes dorsalis, crises of, 282, 702; diagnosis 
of, 703; impairment of muscular sense in, 
702; onset of, 703; pain of, 702; paralysis 
in, 703; pathology of, 701; prognosis of, 
703; symptoms of, 701; treatment of, 
703. 

Tabes mesenterica, 332. 

Table, differentiation, of tuberculous menin- 
gitis and simple meningitis, 747. 

Table, Gower's, for distinguishing epilepsy 
from hysteria, 723. 

Table of calories per pound, 233. 

Table record of experiments upon 1,220 chil- 
dren, giving the age upon which they 
commenced to walk, 92. 



Table showing average percentage of albu- 
minoid matters in diverse articles of food, 
649. 

Tache meningitique, 738. 
Tachycardia, 356, 358, 400, 667, 668. 
Tactus eruditus, 511. 

Taenia, 148; echinococcus, 30; saginata, 29, 

30, 298; solium, 29, 30, 298, 299. 
Talipes equinus, 591. 

Talma's operation in cirrhosis of the liver, 
318. 

Tapeworm, beef, 30, 148; pork, 30, 298, 299. 

Tapping, 391, 405; for ascites, 391; for hy- 
drocele, 405; indications and method of, 
in pleurisy with effusion, 396; in hydro- 
cephalus, 398; the abdomen under local 
anaesthesia, 392. 

Tarsalgia, 687. 

Tartar emetic poisoning, treatment of, 826. 
Taxis 297 298 

Teeth, 254, 256; care of the, 250-256; clean- 
ing the, 254; deformity of the, 256; erup- 
tion of the permanent, 252; Hutchison s, 
500; regulation of the, 256. 

Temperature, 253, 717, 755; in cerebrospinal 
meningitis, 223; in compression of the 
brain, 755; in convulsions, puerperal, 717; 
in fever, 13, 64; normal body, 13; normal, 
in valvular heart lesions, 14; of the new- 
born, 88; taking of, in acute and chronic 
illness, 14. 

Temperatures, subnormal, 65. 

Tendons, 567, 568; dropsy of, 406; lengthen- 
ing of, 567; ossification of, 568; rupture of, 
566, 567; transplantation of, 567, 591; 
tumors of, 568. 

Tenosynovitis, chronic, non-suppurative, 
tuberculous, 567. 

Tent life in tuberculosis treatment, 454, 
456. 

Terrors, night and day, of children, 211. 
Test, 20, 21, 447, 448. 

Test, cream, 118; diazo reaction, 24; Ewald's 
breakfast, 32, 33, 268; Fehling's, 21; fer- 
mentation, for sugar in the urine, 20; for 
acetone in urine of diabetes mellitus, 22; 
for indican in the urine, 22; for lactic acid, 
in stomach contents, 34; Gunzberg's, 31; 
heat and nitric acid, for albumin, 19; 
Leube's, 267; meal, double, 268; milk, 
Babcock's, 118; of Penzold and Faber 
for gastric resorption, 268 ; Penzold's, 
34; quantitative, for urine, 21; Sahli's, 34, 
35; tuberculin, 16, 447, 448; Widal, 56. 

Testicle, inflammation of the, 495; unde- 
scended, 103, 495. 

Testicles and spermatic cord, 495, 496. 

Tetanus in infants, 95; treatment of, 96. 

Tetanus, traumatic, 833. 

Tetany, 693; aetiology of, 693; in infancy, 
211, 212; symptoms of, 693. 

Thecitis, 567. 

Therapeutics, definition of, 57; general, 57; 

mental, and work for the sick, 83. 
Therapy, inhalation, 77 ; serum-, 53, 632, 833. 
Thermoanesthesia, 795. 
Thirst, management of, 73. 



INDEX 



865 



Thoma-Zeiss pipettes, 43. 
Thomsen's disease, 565. 
Thoracoabdomino pagus, 103, 104. 
Thoracocentesis, 394. 

Thorax, fluid in the, 394 ; cedema of the, 
403. 

Thrill, hydatid, 406. 

Thrombosis, 360, 403, 625; cerebral, 696; 
of lateral sinus, 762; of the venous sinuses, 
astiology of, 760, 761; of veins, 361, 403, 
625, 646. 

Thrush, 127, 173; of the oesophagus, 258. 
Thymus gland, abscess and enlargement of, 

170; atrophy of, 142; enlarged, in infants, 

101, 468. 

Thyreoid gland, 664, 665; in cretinism, 667. 

Thyreoid treatment in obesity, 345, 660. 

Tic, 691; convulsif, 691; de pensee, 691; 
douloureux, 686; douloureux, treatment 
of, 688; impulsiv, 691; mimic, 691. 

Tics, 209, 691; facial, 209; psychic, 210; 
treatment of, 692, 693. 

Tinea, 772, 783, 784; capitis, 783; barbae, 
783; circinata, 784; corporis, 784; favosa, 
treatment of, 784 ; furfuracea, 772; ton- 
surans, 783, 784; trichophytina, 783; 
versicolor, 784. 

Tinnitus aurium, 810. 

Tissue specimens, microscopical examina- 
tion of, 50, 51. 

Tobacco, food and digestion, 241. 

Tobacco poisoning, treatment of, 827. 

Toe drop, 591. 

Toes, dead, 734. 

Toes, web fingers and, 104. 

Toilet, nasopharyngeal (Caille), 80, 81. 

Tongue, 73, 127 249, 629; cancer of the, 248; 
bifid, 102; coated, 73; epitheliomatous 
ulceration of the, 248; geographic, 127; 
herpes of the, 249; lymphangioma of the, 
249; parrot, 629; strawberry, 127; tuber- 
culous ulceration of the, 248; ulcer of the, 
247. 

Tongue swallowing, 247. 
Tongue tie, 102, 127. 
Tonics, 82, 83. 

Tonsillitis, 191; symptoms and treatment of, 
192. 

Tonsillotome, McKenzie, 193. 

Tonsils, 153, 424; hypertrophic, in children, 
153, 193, 194; hypertrophy of the, 425, 
426; mycosis of the, 426; removal of, under 
ether, 196. 

Toothache, emergency treatment of, 255. 

Torticollis, 571, 575; acute rheumatic form 
of, 575; acute stage of, 576; as a sequel to 
scarlet fever, 205; chronic stage of, 576; 
congenital, 575; of Pott's disease, 570, 
571, 575; treatment of, 563, 576. 

Touch, bimanual, 508, 509, 511; recto- 
vaginoabdominal, 510; vaginal, 509. 

Toxaemia, 370; intestinal, 142, 301; syphi- 
litic, 749. 

Trachea, tumors, benign, of the, 421. 
Tracheitis in children, 152. 
Tracheoscopy, 413. 
Tracheostenosis, thymic, 170. 



Tracheotomy, 183-190. 
Trachoma, 817. 

Tract, genitourinary, 469-532; genitouri- 
nary, infection of the, 469. 

Tract, respiratory, deep, 431; respiratory, 
upper, erosions and ulcers of the, 418, 
420, 427. 

Trance, 732. 

Transillumination, in examination of the 
nose, 412; in special examinations, 16. 

Transplantation, tendon, 591. 

Transudates, specific gravity in, 37. 

Trembling, of Basedow's disease, 668; of the 
vocal cords, 429. 

Tremors, 678; of palsy, 693. 

Trichiniasis, cedema of, 402, 817. 

Trichocephalus dispar hominis, 31. 

Trismus, 96. 

Trocar (Caille), to prevent blocking in tap- 
ping for ascites, 390, 391. 
Trophic disturbances, 680. 
Tropon, 238. 

Trousseau's symptom, 212, 693, 738. 
Trypanosomiasis, 725. 

Tuberculin, Koch's, 454; test, 16, 447, 448. 

Tuberculosis, 612; bacilli of, in urine, 26; 
cough of, 450, 456; cutis, 788; fever curve 
in, 167; insomnia of, 457; in meningitis, 
747; localized, 536; miliary, 788; of bone, 
536; of the bladder, 491; of the genito- 
urinary tract, 489, 490, 491; of the in- 
testine, 292; of the joints, 557; of the 
kidneys, 469, 473; primary general, 536. 

Tuberculosis, pulmonary, acute, 431, 437; 
treatment of, 437. 

Tuberculosis, pulmonary, chronic, 446; 
anamnesic data of, 447, 452; complica- 
tions of, 451; diet in, 455; incipient stage 
of, 447; lesions in, 451; out of door rest 
cure for, 454, 455; physical signs of, 447, 
450; prophylaxis of, 451; sputum of, 450; 
symptoms of, 447; treatment of, 452, 
453. 

Tuberculosis verrucosa, 789; inflammatory 
and non-inflammatory, 789; treatment of, 
789. 

Tumor, 760, 791; fatty, 791; of the bladder, 
473; of the brain, course of, 760; perfora- 
ting, of the dura, 757. 

Tumor, tubal, 514. 

Tumors, 293, 420, 466, 791; benign, 293, 
420, 421, 466, 491, 493; faecal, 285; fibroid, 
uterine, 528, 529; granulation, 492; in- 
trathoracic, and cysts, 466, 467; malig- 
nant, 327, 466, 467', 468; mediastinal, 468; 
of muscle, 562; of tendons, 568. 

Tumors of the brain, 757, 759, 760; of the 
brain, duration of, 760; of the brain, 
pathology of, 757; of the brain, prognosis 
of, 760; of the brain, "signal symptom" 
of, 759, 760; of the brain, treatment of, 
760. 

Tumors, of the broad ligament, symptoms of, 
527; of the ovaries, symptoms of, 527; of 
the pancreas, 326, 327; stercoral, 285; x 
ray examination for, 467. 

Tympanites, 287. 



866 



INDEX 



Typhoid fever, 29, 318, 612, 624, 628; 
aetiology of, 616; and hepatic abscess, 318; 
and malaria, 612; and Widal reaction, 48; 
Bacillus typhosus in, 29; combined with 
appendicitis, 294; complications and 
sequelae of, 624, 625; definition of, 616; 
diarrhoea of, 624; diazo-reaction test in, 
24; diet in, 623; from rural districts, 618; 
hydrotherapy in, 624; hypinosis in, 369; 
in children, 207; modes of infection of, 
616; personal prophylaxis of, 618; stools 
of, 27; treatment of, 623; treatment of 
bed linen, clothing, etc., used in, 619; 
vomiting in, 628; with bronchitis, 437. 

Typhus fever, 628; complications of, 629; 
definition of, 628; diagnosis and differen- 
tial points of, 630; incubation period of, 
628; invasion of, 629; "parrot tongue" of, 
629; prognosis of, 630; rash of, 629; 
symptoms and course of, 628, 629; treat- 
ment of, 630. 

Ulcer, 279; duodenal, treatment of, 279, 
280; gastric, treatment of, 280; intestinal, 
141, 291, 292; of the leg, treatment of, 
773; of the oesophagus, 259; of the rectum, 
309; of the stomach, 279, 282; of the 
tongue and its frenum, 247; peptic, 279; 
perforating, of the foot, 796; rodent, 793; 
tonsillar, of Vincent, 173. 

Ulceration, 247, 310, 311; and stricture of 
the rectum, diagnosis, prognosis, symp- 
toms, and treatment of, 310, 311; dental, 
247; dental (Riga's disease), 127; in the 
bladder, 487; of the tongue, epitheliom- 
atous, 248. 

Ulcers, 418, 419, 420; carcinomatous, 420; 
of the pharynx, 419; superficial simple, 
418. 

Umbilicus, eczema of the, 95. 
Uncinaria americana, 299. 
Uncinaria duodenalis, 300. 
Urachus, patent, 486. 

Uraemia, 55, 370, 471, 480; in nephritis, 481, 
482; test for, 55. 

Urea, normal amount excreted in twenty- 
four hours, 22. 

Ureter, extirpation, total, of the, 486. 

Ureters, kinking of the, 485. 

Urethritis, latent specific, 507; posterior, 
acute, 502; posteroanterior, 504, 505. 

Urination, 471; difficult, 475; remarks on, 
475. 

Urine, 24, 25, 475, 476; albumin in the, 19; 
alkaline, 19; blood in, 25; blood pigment 
in the, 473; casts in the, 24, 25; chlorides 
in the, 23; color of, 18, 471; consistence 
of, 18; daily amount of, passed by adults, 
471; daily amount of, passed by children, 
470 ; disinfection, importance of, in ty- 
phoid fever, 618; examination of, appa- 
ratus necessary for, 17, 18; gonococci in, 
26; haemoglobin in the, 22; incontinence 
of, 475; in diabetes, 653; in hysteria, 729; 
inorganic elements in, 26; microscopical 
examination of the, 24; mucus in, 22; odor 
pf, 18; parasites in, 26; peptone in the, 20; 



picric acid test for, 19; pus in, 26, 474; 
quantitative test for, 21; quantity of water 
secreted in, 470; reaction of, 18; retention 
of, 475; solids, total, in the, 470; specific 
gravity of, 19, 471; stagnation of, 469; 
sugar in the, 20; suppression of, 476; 
turbidity of, 18. 
Urticaria, 247, 781. 

Uterus, 514, 530; and ovaries, prolapse of 
the, 523; anomalies of the, 514; cancer of 
the body of the, 530; displacements of the, 
diagnosis of the, 514; inversion of the, 514; 
prolapse of the, 523, 524; unicornis, 
514. 

Uvula, bifid, 102. 
Vaccination, 640. 

Vaccinia, 640; complications of, 640. 

Vaginismus, treatment of, 520. 

Varicella, 201, 604, 774; gangrsenosa, 774; 
period of isolation for, 604; symptoms and 
treatment of, 201. 

Varicocele, 496; treatment of, 496. 

Varicosities in the lower extremities, 361. 

Variola, 634, 636, 639; clinical varieties of, 
634; confluent, 636; definition of, 634; 
desiccation of, 636; diagnosis and differ- 
ential points of, 639; diet of, 639; drug 
treatment in, 639; eruption of, 636; in- 
cubation period of, 635; invasion of, 635; 
prognosis of, 638; prophylaxis for, 639; 
rash of, 635, 636; symptoms of, 634; tem- 
perature in, 636. 

Varioloid, 637; complications of, 637, 638. 

Vasomotor and trophic disturbances, 734. 

Vegetarianism, 240. 

Veins, 359, 361; diseases of the, 359; inflam- 
mation of the, 361; varicose, 361, 496. 

Venesection, 79, 80; and local depletion, 79, 
80; for cardiac embarrassment, 79; in chil- 
dren, 80; in dropsy, 389; in valvular heart 
disease, 352, 353; technique of, 79, 80. 

Verruca, 792; acuminata, 792; condyloma, 
792; digitata, 792; filiformis, 792; plana, 
792; syphilitica, 792; treatment of, 792; 
vulgaris, 792. 

Vertigo, 810; aetiology of, 714; arteriosclerot- 
ic, 715; auditory, 715; aural, 810; diag- 
nosis, prognosis, and treatment of, 715; 
mechanical, 715; neurasthenic, 715; neu- 
rotic, 715; ocular, 715, 814; of the larynx, 
429; senile, 715; stomachic, 715. 

Vesicles, seminal, stripping the, for pros- 
tatitis, 495. 

Vibration, mechanical, 600. 

Vibration massage in dyspepsia and catarrh 
of the stomach, 597. 

Virgines intactae, bimanual examination of, 
511. 

Visceral neuralgias in heart disease, 355. 

Vitiligo, 772. 

" Voix de canard," 197. 

Volvulus, 296. 

Vomit, black, of yellow fever, 628. 
Vomit, parasites (worms) in, 32. 
Vomiting, 73, 262; in diphtheria, 177; of 
acute leptomeningitis of adults, 740; of 



INDEX 



867 



infants, 129, 130; of peritonitis, 330; in 

scarlet fever, 205; of yellow fever, 628. 
Von Graefe's sign in Basedow's disease, 668. 
Vulvovaginitis in children, gonorrhceal, 

simple purulent, 208; treatment of, 208, 

209. 

Vulvovaginitis, specific, rules to prevent the 
spread of, 609. 

Walking of children, 92; causes which may 

retard, 220. 
Wart, 792, 793; anatomical, 789. 
Warts, 792. See Verruca. 
Warts of the eyelids, 816. 
Water, 51, 116; bacteriological examination 

of, 51; boiled as a diluent for infant food, 

116; drinking, analysis of, 51. 
Water blisters, 779. 
Waterlogged patients, 388, 389. 
Waters, mineral, 237. 
Weakness, heart, 335. 
Weaning, 109, 112. 
Web fingers and toes, 104. 
Weights and measures, rules for converting 

apothecaries' into the metric system, 86. 
Werlhoff 's disease, 383. 
Westphal's symptom, 702. 
Wet brain, 397. 
Wheals, 781. 

Whey, as a diluent for infants' food, 116, 117. 

Whitehead's method for treatment of hem- 
orrhoids, 308. 

White swelling of osteomyelitis, 537. 

White swelling, symptoms of, 587. 

Whooping cough, 168, 169, 604; complicat- 
ing phenomena and clinical varieties, 68; 



intubation in, 169; paroxysms of, 169; 

phenomena and clinical varieties of, 168; 

pseudo, 169. 
Widal reaction, 47, 56; microscopic, 48. 
Winckel disease, 92. 
Wines, 237. 
Wolff's law, 569. 

Worm, 30, 148, 771; beef tape, 298; palisade, 
492; pin, 30, 148; round, 30, 31. 148; tape, 
148. 

Wormian bodies (in infants), 106. 

Worms, 30, 208; flesh, 771; in children, 148; 

tape, 30, 148. 
Wounds, infected, of the eye, 816; septic, 

823. 

Wrist drop, 713. 

Xanthoma diabeticorum, 793. 
Xanthoma planum, 793. 
Xanthoma tuberculosum, 793. 
Xeroderma, 782. 
Xerostomia, 243. 

X Rays, 16, 270, 448, 588; examination of 
the lower gut with, 270; examination of 
the stomach with, 267; in knee disease, 
535,588; in tuberculosis, 448, 449; in tu- 
mors, 467. 

Yaws, 789. 
Yeast fungi, 782. 

Yellow fever, 627, 628; aetiology of, 627; def- 
inition of, 627; diagnosis of 628; prognosis 
of, 628; prophylaxis of, 628; pulse in, 627; 
symptoms of, 627; temperature in, 627; 
treatment, immediate, of, 628; vomiting 
in, 628. 



a. 



THE END 



NORMAL 
HISTOLOGY 

BY 

JEREMIAH S. FERGUSON, M.Sc, M.D. 

Instructor in Histology, Cornell University Medical College, New York City 

With 462 Illustrations, many in colors 
Cloth, $4.00 Half Leather, $4.50 

SOLD ONLY BY SUBSCRIPTION 



"This is an eminently practical and useful book, and one in which the subject 
is treated exhaustively. The author has that all too rare faculty of making 
things plain which comes from full knowledge and an aptitude for teaching. 
Since histology is at the basis of our comprehension of physiology, pathology, 
bacteriology, and clinical medicine unusual space has been devoted to all those 
organs which serve as a field for the specialist in medicine. This is especially 
true of the chapters on the central nervous system, which are comprehensive 
and exhaustive. What is true of this department is more or less true of all, and 
specialists, practitioners, and students will find a sufficiently adequate treatment 
of the histology of every tissue of the body." — Medical and Science Journal . 

" The subject-matter in this excellent book is thoroughly modern, and is 
presented in clear and readable fashion, while the unusual profusion and quality 
of the illustrations contribute a great deal to the attractiveness of the volume. 
An interesting feature is the free use of drawings made from plastic recon- 
structions of organs, which should be of great assistance to the student in 
understanding such structures as the adrenals, various glands, the blood, and 
lymphatic systems of different regions, etc. . . . The minute anatomy of the eye 
and of the ear is discussed at much greater length than is customary, and the 
section devoted to the nervous system is also worthy of note, both on account 
of its completeness and of the character of its illustrations. The bibliography is 
conveniently grouped by topics at the end of the volume and presents a well- 
selected list of the more important contributions to histological literature." 

■ — New York Medical Record. 

" Both as to text and illustrations this work is the most comprehensive and 
best-arranged text-book on the subject which has as yet appeared in this 
country." — Albany Medical Annals. 

" This recent claimant to favor should easily dispel existing impressions as 
to the superiority of foreign works, for Dr. Ferguson has written a work of which 
nothing but praise can be spoken." — Medical Monthly, Memphis, Tenn. 



D. APPLETON AND COMPANY, Publishers 
436 Fifth Avenue, New York. 



2 7 37 




DISEASES OF THE HEART 
AND ARTERIAL SYSTEM 

By ROBERT H. BABCOCK, A.M., M.D. 

Professor of Clinical Medicine and Diseases of the Chest, College of Physicians' 
and Surgeons (Medical Department of the Illinois State University), 
Chicago ; Attending Physician to Cook County Hospital for 
Consumptives ; Fellow and former President of the 
American Climatological Association, etc. 

Three Colored Plates and One Hundred and Thirty-nine 
Illustrations in the Text. 8vo. Cloth, $6.00 

SECOND EDITION 
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" This treatise is evidently the result, not only of large clinical experience, but of 
wide reading and careful reflection. The author disclaims any pretense of originality, 
but it is open to question whether the conclusions and results of a ripe judgment, such 
as are presented in this volume, are not worth quite as much as some academic so- 
called original work. Certainly a large amount of material, both clinical and literary, 
has been worked out and presented in a most clear, succinct, and practical manner. 
The author's style is pleasing and without ambiguity, nor is the text over-loaded with 
unnecessary technical terms. Alter a careful perusal of Dr. Babcock's book there are 
two features which strike the reader as characteristic and valuable. These are, on 
the one hand, the case histories, and, on the other, the unusual number and vatue of 
the pages devoted to the therapeutics of the subject. The narration of cases, although 
at times in much detail, does not cause the usual weariness of flesh in the reading, 
mainly because of the interesting manner in which they are written. They are 
particularly well chosen to illustrate the manifold varieties of disease and the practical 
wisdom required in the management of actual cases. Regarding the therapeutic side 
of the work none but words of praise are required. So far as the reviewer's reading 
goes there is no more complete and reliable exposition of the treatment of circulatory 
disease than that found in this volume. That this high commendation is deserved will 
readily be admitted after reading chapters 16, 17, and 18 upon the treatment of valvular 
heart disease. These chapters are distinguished by a fulness of detail and a variety of 
therapeutic resource which cannot but prove of great value, not only to the young 
practitioner, but, as well, to the clinician of years. 

"The book can be unhesitatingly recommended as a distinct acquisition to one's 
working library." — "Brooklyn Medical Journal. 

" We commend to our readers this work of Babcock's as a very desirable work 
for both the specialist and the practitioner, and wish the author a most hearty wel- 
come for his admirable literary endeavor." — Medical News. 



D. APPLETON AND COMPANY, NEW YORK. 



